No-Fault Case Law

The court considered the fact that the plaintiff had moved for summary judgment to recover assigned first-party no-fault benefits, and the defendant had cross-moved for summary judgment, claiming the action was premature because they had requested verification that had not been provided. The main issue decided was whether the defendant had received the requested verification, which would start the 30-day period within which they were required to pay or deny the claims. The holding of the court was that as the defendant demonstrated they had not received the verification, and the plaintiff did not show it had been provided, the action was considered premature. Therefore, the defendant's cross motion for summary judgment to dismiss the complaint was granted.

The court considered the appeal of the Civil Court of the City of New York, Kings County, which had granted the defendant's motion for summary judgment dismissing the complaint by Mind & Body Acupuncture, P.C., as assignee of Jessica Torres, seeking to recover assigned first-party no-fault benefits. The defendant alleged that the claims had been properly denied because the plaintiff's assignor had failed to appear at duly scheduled examinations under oath (EUOs). However, the defendant failed to establish that the initial and follow-up EUO scheduling letters had been timely mailed, and therefore failed to demonstrate that the EUOs had been properly scheduled. Consequently, the defendant was not entitled to summary judgment dismissing the complaint. The Appellate Term, Second Department reversed the order and denied the defendant's motion for summary judgment.

The relevant facts the court considered were that Jaga Medical Services, P.C. filed a motion for summary judgment to recover assigned first-party no-fault benefits, and American Transit Ins. Co. filed a cross motion for summary judgment to dismiss several causes of action. The main issues decided by the court were whether the amounts sought in the unpaid portions of the claims exceeded the amounts permitted by the workers' compensation fee schedule, and whether there was a lack of medical necessity for the services at issue. The holding of the case was that the court affirmed the order, denying the branches of plaintiff's motion seeking summary judgment and granting the branches of defendant's cross motion seeking summary judgment dismissing the causes of action. The court found that the defendant had properly used the workers' compensation fee schedule to determine the amount the plaintiff was entitled to receive and that there was a lack of medical necessity for the services at issue.

The court considered a motion for summary judgment by a medical provider to recover first-party no-fault benefits, and a cross-motion for summary judgment by the insurance company to dismiss the complaint based on the assignor's failure to appear for scheduled independent medical examinations. The main issue decided was whether the denial of claim forms had been timely and properly mailed by the insurance company. The court held that the insurance company's submissions were sufficient to presume that the denial of claim forms had been timely and properly mailed, and therefore affirmed the order denying the provider's motion for summary judgment and granting the insurance company's cross-motion.

The court considered whether the defendant had properly mailed the independent medical examination (IME) scheduling letters to the plaintiff's assignor. The main issue was whether the defendant had established the timely and proper mailing of the IME scheduling letters, which are necessary for the provider to recover assigned first-party no-fault benefits. The court held that the defendant had failed to establish the timely and proper mailing of the IME scheduling letters. The defendant's moving papers stated that the letters are sent to the address the assignor puts on the NF-2 form or to the address provided by the assignor's counsel, but there was a discrepancy in the address listed on the NF-10 form and where the letter was sent to. The court affirmed the order denying the defendant's motion for summary judgment dismissing the complaint, stating that the defendant's moving papers failed to demonstrate that the IMEs had been properly scheduled.

The court considered the proof submitted by the defendant in support of its cross motion for summary judgment, which did not establish as a matter of law its defense that the plaintiff's assignor's injuries did not arise from a covered incident. The main issue decided was whether defendant's cross motion for summary judgment should have been denied. The holding of the case was that the order, insofar as appealed from, is reversed and defendant's cross motion for summary judgment dismissing the complaint is denied.

The court considered the appeal from an order of the Civil Court of the City of New York which denied defendant's motion for summary judgment dismissing the complaint in the case of Brand Medical Supply, Inc. v Praetorian Insurance Company. The main issue decided was whether defendant demonstrated that plaintiff's assignor had failed to comply with a condition precedent to coverage and that defendant had timely denied the claim on that ground, as well as whether the IME scheduling letters had been timely mailed and the plaintiff's assignor had failed to appear for the scheduled IMEs. The holding of the court was that since defendant demonstrated that plaintiff's assignor had failed to comply with a condition precedent to coverage and that defendant had timely denied the claim on that ground, the Civil Court should have granted defendant's motion for summary judgment. Therefore, the order was reversed and defendant's motion for summary judgment dismissing the complaint was granted.

The court considered an order from the Civil Court of the City of New York, Queens County which denied the branches of the plaintiff's motion seeking summary judgment on the first through fourth causes of action and granted the branches of defendant's cross motion seeking summary judgment dismissing those causes of action. The main issue in the case was whether the defendant had properly used the workers' compensation fee schedule to determine the amount which the plaintiff was entitled to receive for the services at issue in the second and third causes of action, and whether the requested verification had been received by the defendant for the fourth cause of action. The holding of the case was that the defendant had demonstrated that it had not received the requested verification for the fourth cause of action, and that the defendant had properly used the workers' compensation fee schedule for the services at issue in the second and third causes of action. The court affirmed the order with costs.

The court considered the denial of claim forms from the defendant and found that they were sufficient to advise the plaintiff that the claims were partially denied because the fees were not in accordance with the workers' compensation fee schedule. The court also found that the defendant's evidence was sufficient to establish that the independent medical examination (IME) scheduling letters had been timely mailed. However, the court decided that the claims in the sums of $290.74 and $210.72 had not been timely denied and that the defendant had not demonstrated that it was not precluded from asserting its defense that the amounts sought to recover were in excess of the workers' compensation fee schedule. As a result, the court held that the branches of the defendant's motion seeking summary judgment dismissing the claims in the sums of $290.74 and $210.72 were denied.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits. The main issue was whether the defendant was entitled to an examination before trial of the plaintiff's owner, as well as the plaintiff's motion for summary judgment pending the completion of discovery. The court held that the defendant was entitled to an examination before trial of the plaintiff's owner, citing relevant statutes and previous cases. The court affirmed the order of the Civil Court, dismissing the portion of the appeal related to the continuation of plaintiff's motion for summary judgment and ordering the plaintiff to pay $25 in costs.