No-Fault Case Law

In this case, MB Advanced Equipment, Inc. brought a lawsuit against New York Central Mutual Fire Insurance Company to recover assigned first-party no-fault benefits. The insurance company had denied the claims at issue based on the failure of the plaintiff's assignors to appear for duly scheduled independent medical examinations (IMEs). The main issue for trial was whether the plaintiff's assignors had failed to appear for the IMEs. The Civil Court made findings in favor of the plaintiff, stating that the insurance company's denial of claim forms had been timely and proper, and that the plaintiff had established its prima facie case. The appellate court affirmed the lower court's decision, stating that the insurance company did not provide sufficient basis to strike the Civil Court's findings. Therefore, the order denying the insurance company's motion for summary judgment was affirmed.

The court considered the facts surrounding the denial of the defendant's motion for summary judgment in a case where a provider was attempting to recover assigned first-party no-fault benefits. The main issue decided in this case was whether the defendant had established its entitlement, as a matter of law, to judgment dismissing the complaint on the ground that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs). The court held that the defendant had failed to establish its entitlement to judgment on this ground, as the doctor who was scheduled to perform the IMEs did not establish that she possessed personal knowledge of the nonappearance of the plaintiff's assignor. Additionally, the court found that there were triable issues of fact regarding the grounds of lack of medical necessity and the amounts sought exceeding the amounts permitted by the workers' compensation fee schedule, based on affidavits submitted by the plaintiff's owner. Therefore, the court affirmed the denial of the defendant's motion for summary judgment.

The court considered the facts of the case, which involved Harvard Medical, P.C. seeking to recover assigned first-party no-fault benefits from Tri State Consumers Ins. Co. The main issue decided was whether the defendant had fully paid the plaintiff in accordance with the workers' compensation fee schedule. The court granted the defendant's motion for summary judgment, dismissing the complaint. The holding of the case was that the order granting the defendant's motion for summary judgment was affirmed. The decision was based on the reasons stated in another case, Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co., which was decided at the same time.

The relevant facts considered by the court in this case were that GBI Acupuncture, P.C., as the assignee of Sofia Gjonbalaj, brought an action against Tri State Consumers Ins. Co. to recover assigned first-party no-fault benefits. The main issue decided by the court was whether the defendant had fully paid the plaintiff in accordance with the workers' compensation fee schedule. The holding of the case was that the Civil Court granted the defendant's motion for summary judgment, and the Appellate Term affirmed this decision. The court referenced a similar case, Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co., in making their decision.

The main issue in this case was whether the action to recover assigned first-party no-fault benefits was premature, as the defendant claimed, due to not receiving requested verification. The court considered the fact that the defendant had timely mailed the verification request and follow-up verification request and had not received the requested verification, which would support the defendant's claim. However, the plaintiff submitted an affidavit from the owner, giving rise to a presumption that the requested verification had been mailed to and received by the defendant, creating a triable issue of fact. The court ultimately held that there was a triable issue of fact as to whether the action was premature, and therefore affirmed the lower court's decision to deny the defendant's motion for summary judgment dismissing the complaint.

The court considered an appeal from an order and judgment of the Civil Court of the City of New York, which denied a petition to vacate an arbitration award in favor of the respondent, and granted the respondent's cross-motion to confirm the arbitration award. The issue decided was whether the $50,000 limit of the subject insurance policy was exhausted before the petitioner-insurer was obligated to pay the respondent's claim. The court held that an arbitrator's award directing payment in excess of the monetary limit of a no-fault insurance policy exceeds the arbitrator's power and constitutes grounds for vacatur of the award. The matter was remanded to Civil Court for a framed issue hearing regarding whether the $50,000 policy limit was exhausted before the petitioner was obligated to pay the claims at issue. The court also held that the petitioner was not precluded by regulations from paying other legitimate claims subsequent to the denial of the respondent's claims, and adopting the respondent's position would require the petitioner to delay payment on uncontested claims pending resolution of the respondent's disputed claim, which goes against the no-fault regulatory scheme designed to promote prompt payment of legitimate claims.

The relevant facts of the case were that a master arbitrator's award was given to the respondent, Professional Chiropractic Care, P.C., after their assignor failed to attend scheduled independent medical exams. The main issue decided on was whether the no-fault policy issued by the petitioner was void due to the assignor's actions, and the alleged error in the petitioner's denial of the claim form. The court reversed the order of Supreme Court, Bronx County that denied the petition to vacate the master arbitrator's award, and granted the petition, vacating the award. The holding of the case was that the master arbitrator's award was arbitrary because it irrationally ignored the law, which the insurer had presented, that the no-fault policy was void ab initio due to the assignor's actions. The alleged error in petitioner's denial of claim form was not considered a sufficient or rational basis for the award.

The main issue of the case was whether the plaintiff, NY Rehab Pain Management & Medical Services, P.C. (“NY Rehab”), was entitled to recover first party no-fault benefits for services provided to treat an individual injured in an auto accident, in light of the plaintiff's failure to appear for an Examination Under Oath (“EUO”) as requested by the defendant, State Farm Auto Ins. Co. The court held that the plaintiff's failure to comply with the EUO request constituted a material breach of the insurance policy and the No-Fault regulations, precluding recovery of the policy proceeds. The court considered the correspondence and documentary evidence submitted by State Farm, including affidavits of employees explaining the insurance company's procedures for mailing notices and conducting EUOs, as well as affidavits attesting to the plaintiff's non-appearance at the scheduled EUOs. The court found that the plaintiff's belated objections to the EUO request and outstanding discovery did not excuse its breach of the policy and regulations. Consequently, the court granted State Farm's motion for summary judgment and dismissed the plaintiff's complaint.

The court considered a case in which a medical provider, Maxim Tyorkin, sought no-fault benefits from Garrison Property & Casualty Ins. Co. Defendant challenged the claim on the basis of negative peer reviews of the services rendered and claimed that the medical provider billed above the New Jersey Fee Schedule. The court had to decide whether the insurer was required to issue a Denial of Claim form when receiving a bill from a medical provider who rendered services in a different state. The court held that the defense based on the negative peer review was precluded due to the insurer's failure to issue a Denial of Claim form, as required by the regulations. Additionally, the court held that the fee schedule defense was not precluded and the medical provider was only entitled to reimbursement at the rates permissible and authorized in the state of New Jersey. The court granted Plaintiff's motion for summary judgment to the extent that it established its prima facie case, and Defendant's cross-motion was also granted to the same extent, thus leaving the fee schedule defense as the sole issue for trial.

The relevant facts of this case involved a medical provider, AAAMG Leasing Corp., making a claim for no-fault benefits from an insurance carrier, GEICO Insurance Company, which was denied for not being medically necessary. The matter was then taken to arbitration, and the arbitrator initially awarded the medical provider a sum of $3,870.45 plus interest, and an attorney’s fee of $850. Subsequently, a master arbitrator affirmed this original arbitration award and also awarded an additional attorney's fee of $650, which was the maximum allowable fee. GEICO Insurance Company commenced a proceeding to vacate the master arbitration award which the Supreme Court denied, but did not comment on the medical provider's request for an additional attorney’s fee of $650, leading the Appellate Division to grant the award of additional attorney's fee in the sum of $650 to the medical provider. The main issue decided by the Appellate Division was whether the medical provider was entitled to the additional attorney's fee pursuant to insurance department regulations. The limitation on the attorney’s fee recoverable in an appeal from a master arbitration award was set forth in Insurance Department Regulations, and the court found that the medical provider did not ask for an attorney's fee for oral argument and there was no finding that the issues involved were novel or unique, hence, they were entitled to an award of an additional attorney’s fee in the sum of $650. As a result, the holding of the case was that the order and judgment of the Supreme Court was reversed and the award of the additional attorney’s fee in the sum of $650 was granted.