No-Fault Case Law

The court considered a case in which Professional Health Imaging, P.C. sought to recover first-party no-fault benefits as the assignee of Crystal Perez from State Farm Mutual Automobile Insurance Co. State Farm filed a motion for summary judgment to dismiss the complaint on the ground that Professional Health Imaging had failed to appear for scheduled examinations under oath. The Civil Court initially denied State Farm's motion, citing a disputed issue of fact regarding whether Professional Health Imaging had appeared for the examinations. However, State Farm's evidence showed that the scheduling letters for the examinations had been timely mailed and that Professional Health Imaging had failed to appear, thus failing to comply with a condition precedent to coverage. As a result, the Appellate Term reversed the denial of State Farm's motion and granted summary judgment in favor of State Farm, dismissing the complaint.

The main issue in the case of Kemper Independence Ins. Co. v Adelaida Physical Therapy, P.C. was whether the insurance company was obligated to provide no-fault benefits to the defendants who failed to appear for their scheduled examinations under oath (EUO) due to a motor vehicle accident. The lower court had granted the plaintiff's motion for summary judgment, declaring that the plaintiff was not obligated to provide benefits to the defendants. However, the Appellate Division reversed the judgment, stating that the plaintiff failed to supply sufficient evidence to determine if the notices served for the EUOs were subject to timeliness requirements and if the notices had been served in conformity with those requirements. The plaintiff failed to establish that the EUOs were not subject to the procedures and time frames set forth in the no-fault regulations and that they had properly noticed the EUOs in conformity with their terms. Thus, the motion was denied, and the judgment vacated.

The main issue in the case was whether the defendant, GEICO, timely and properly requested additional verification from the plaintiff, St. Barnabas Hospital, upon its receipt of proof of the claim which effectively tolls the 30-day time period within which GEICO must pay or deny the claim for services rendered in the amount of $43,212.59. The court held that the plaintiff's initial claim for payment was premature and was not complete until the defendant received additional verification of the claim as requested. The court also ruled that the hospital's response was vague and did not address the request for breakdown of charges up to where the patient was found to be stabilized. Ultimately, the court granted the defendant's cross motion for summary judgment and dismissed the complaint.

The main issue in this case was whether or not the defendant properly used the workers' compensation fee schedules to reimburse the plaintiff for acupuncture services rendered. The court considered the affidavit of the defendant's litigation examiner and exhibits annexed in support of the defendant's motion, which established that the defendant had fully paid the plaintiff in accordance with the workers' compensation fee schedules for the services provided. Additionally, the sworn report of the defendant's expert established a lack of medical necessity for certain services for which the defendant had denied reimbursement. The court found that the plaintiff failed to raise a triable issue of fact in opposition to the defendant's motion with respect to either of the proffered defenses. Therefore, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The relevant facts considered by the court were that Exon Medical Equipment, Inc. was seeking to recover no-fault benefits as an assignee of MADIKABA TOUNKARA, but the defendant, State Farm Mutual Automobile Ins. Co., had filed a motion for summary judgment dismissing the complaint on the grounds that the plaintiff had failed to provide requested verification. The main issue decided was whether the plaintiff had provided the necessary verification to support their claim for no-fault benefits. The holding of the court was that the order granting the defendant's motion for summary judgment was affirmed, without costs, on the basis that the plaintiff had indeed failed to provide the required verification. This decision was made in concurrence by the appellate judges.

The main issue in this case was whether the defendant insurance company had issued a timely denial of claim that was conclusory, vague, or without merit as a matter of law, which is a requirement under Insurance Law. The court found that the plaintiff had failed to establish a prima facie case in this regard, and that the defendant's papers did not establish that the plaintiff's assignor had failed to appear for two duly scheduled examinations under oath (EUOs). As a result, the Civil Court correctly found that the defendant had failed to establish its entitlement to summary judgment dismissing the complaint. The holding of the court was that the judgment in favor of the plaintiff was reversed, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion was denied.

The court considered an appeal from an order of the Civil Court of the City of New York, Queens County, which granted the defendant's motion to dismiss the complaint and denied the plaintiff's cross motion for leave to renew its prior motion for summary judgment. The main issue decided in the case was whether the provider could recover assigned first-party no-fault benefits. The court affirmed the order, stating that for the reasons stated in a similar case, the order is affirmed. The holding of the case was that the order granting the defendant's motion to dismiss the complaint and denying the plaintiff's cross motion for leave to renew its prior motion for summary judgment was affirmed.

The court considered that the plaintiff, Flatbush Chiropractic, P.C., had moved for summary judgment to recover first-party no-fault benefits, but the defendant, American Transit Ins. Co., argued that there was a question as to whether the assignor had been injured during the course of his employment, which should be submitted to the Workers' Compensation Board. The Civil Court initially denied plaintiff's motion for summary judgment and granted defendant's cross motion, finding that resolution from the Board was required. The court further stated that the action may be dismissed if the matter was not filed with the Board within 90 days. Defendant later moved to dismiss the complaint based on plaintiff's failure to comply with the Civil Court's order, and plaintiff cross-moved for leave to renew its motion for summary judgment based on new evidence. The court found that plaintiff did not demonstrate that the assignor had made a proper application for workers' compensation benefits and denied plaintiff's cross motion for leave to renew and granted defendant's motion to dismiss the complaint. Therefore, the court affirmed the order.

The court considered the appeal from an order of the District Court of Suffolk County, which granted defendant's motion for summary judgment dismissing the complaint in a case brought by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant had taken an adversarial position during claims processing in violation of 11 NYCRR 65-3.2 (b). The court held that there was no merit to the plaintiff's argument on appeal that the defendant had clearly taken an adversarial position during claims processing and affirmed the order of the District Court.

The court considered the case of Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. in which the appellant sought to recover assigned first-party no-fault benefits. The main issue decided by the court was whether the defendant was entitled to summary judgment dismissing the complaint based on the argument that it had fully paid the plaintiff for the services at issue in accordance with the workers' compensation fee schedules. The court held that the defendant was not entitled to summary judgment because the workers' compensation fee schedules did not assign a relative value to the services at issue, and the defendant did not request additional verification from the plaintiff as required in order to review the claims for those services. Therefore, the branches of defendant's motion seeking summary judgment dismissing the complaint as it related to these services were denied.