No-Fault Case Law

The court considered an order of the Civil Court of the City of New York, Queens County, which granted defendant's motion for summary judgment dismissing the complaint brought by Omphil Care, Inc., as the assignee of FRANTZ MENARD, to recover first-party no-fault benefits from State Farm Mutual Automobile Ins. Co. The main issue decided was whether State Farm had timely and properly denied the claims at issue on the ground that the plaintiff had failed to comply with a condition precedent to coverage by not appearing for duly scheduled examinations under oath (EUOs). The court held that the defendant did have justification for its EUO requests, and therefore affirmed the order of the Civil Court, dismissing the complaint.

The main issues in this case were whether the defendant was entitled to summary judgment dismissing the complaint and whether the plaintiff was entitled to recover assigned first-party no-fault benefits. The court considered the defendant's motion for summary judgment or to compel the plaintiff's treating doctor to appear for examination before trial, as well as the plaintiff's cross-motion for summary judgment. The court held that with respect to all of the remaining claims, the sole issue for trial was the defendant's defense of lack of medical necessity. The court ultimately reversed the order, granted the defendant's motion seeking summary judgment dismissing the complaint, except for certain claims, and held that the defendant owed the plaintiff the additional sum sought for specific claims.

The court considered the facts of a lawsuit brought by New Quality Medical, P.C., as the assignee of Henry Munoz, against Allstate Insurance Company to recover assigned first-party no-fault benefits. Allstate Insurance Company had moved for summary judgment, arguing that they had timely and properly denied the claims due to the plaintiff's failure to appear for duly scheduled examinations under oath (EUOs). However, the plaintiff argued that Allstate had not established their failure to appear for the EUOs. The main issue decided was whether Allstate had submitted sufficient proof of the plaintiff's nonappearance for the EUOs. The court held that because Allstate failed to submit proof by someone with personal knowledge of the nonappearance of the plaintiff for the EUOs in question, Allstate's motion for summary judgment should have been denied. Therefore, the court reversed the order of the Civil Court and denied Allstate's motion for summary judgment dismissing the complaint.

The court considered the motion for summary judgment by the plaintiff to recover assigned first-party no-fault benefits, and the defendant's cross motion for summary judgment dismissing the complaint. The defendant alleged that the claim had been timely and properly denied based on the plaintiff's failure to appear at scheduled examinations under oath (EUOs). The Civil Court granted the plaintiff's motion and denied the defendant's cross motion, finding that the defendant had failed to sufficiently establish the plaintiff's failure to appear for EUOs. The main issue decided was whether the defendant had submitted enough proof of the plaintiff's failure to appear for the EUOs, and the court held that the defendant had failed to raise a triable issue of fact as to whether it had timely denied the plaintiff's claims, affirming the order with costs.

The court considered the motion for summary judgment made by defendant to dismiss the complaint on the ground of lack of medical necessity in an action by a provider to recover assigned first-party no-fault benefits. The court initially denied defendant's motion for summary judgment, as the affidavit of mail clerk demonstrated the existence of a triable issue of fact. Defendant then sought leave to renew their motion based on new facts and an affidavit explaining an inadvertent typographical error in the previous motion. The court held that the branch of defendant's motion seeking leave to renew was granted, and that upon renewal, the order denying the motion for summary judgment was vacated and defendant's prior motion was granted. This decision was based on the submission of evidence that the verification requests and denial of claim forms were timely mailed, and the submission of an affirmed peer review report providing a medical rationale for the determination that there was no medical necessity for the supplies furnished.

The relevant facts in this case were that Ther-Ox Home Care, Inc. was seeking to recover assigned first-party no-fault benefits from Praetorian Insurance Company. The main issue decided was that the Civil Court denied defendant's motion for summary judgment dismissing the complaint, but limited the issues for trial to the medical necessity of the supplies in question. The holding of the case was that the Appellate Term, Second Department reversed the order and granted defendant's motion for summary judgment dismissing the complaint, citing that the plaintiff's affidavit from a doctor failed to sufficiently rebut the conclusions set forth in the peer review report provided by the defendant. Ultimately, the court found that there was a lack of medical necessity for the supplies at issue.

The relevant facts considered by the court in Renelique v New York Cent. Mut. Fire Ins. Co. were that the plaintiff, Pierre Jean Jacques Renelique, was seeking to recover assigned first-party no-fault benefits. The defendant, New York Central Mutual Fire Insurance Company, had denied the claims based on the plaintiff's assignor's failure to appear for independent medical examinations. The main issue decided was whether the denial of the claim form was timely and properly mailed by the defendant. The court held that the affidavit submitted by the defendant established the timely and proper mailing of the denial of claim form, and as a result, the court affirmed the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint.

The relevant facts that the court considered were that the defendant, Tri State Consumers Ins. Co., had fully paid the plaintiff in accordance with the workers' compensation fee schedule. The main issue decided was whether the defendant had fully paid the plaintiff, who was seeking to recover assigned first-party no-fault benefits. The holding of the case was that the Civil Court granted defendant's motion for summary judgment dismissing the complaint, and this decision was affirmed by the Appellate Term, Second Department in their order.

The relevant fact considered by the court was that the defendant had fully paid the plaintiff in accordance with the workers' compensation fee schedule. The main issue decided was whether the defendant was precluded from raising its defense that the fees charged exceeded the amount allowed by the workers' compensation fee schedule because it was not set forth with sufficient particularity in the denial of claim form. The court held that the defendant was not precluded from raising this defense, and as such, affirmed the lower court's order granting summary judgment in favor of the defendant.

The court considered the motion for summary judgment by the plaintiff, who was seeking to recover first-party no-fault benefits as an assignee of Michelle Thane. The defendant cross-moved for summary judgment, arguing that the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The main issue was whether the defendant had established that the assignor had failed to appear for the IMEs, as this was a condition precedent to the insurer's liability on the policy. The court held that the affidavits submitted by the defendant were sufficient to establish that the assignor had failed to appear for the scheduled IMEs, and therefore, the plaintiff's motion for summary judgment was denied and the defendant's cross-motion was granted. The remaining contention raised by the plaintiff was not properly before the court and was declined to be considered.