No-Fault Case Law

GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U))

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.
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Great Health Care Chiropractic, P.C. v Hereford Ins. Co. (2016 NY Slip Op 50858(U))

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.
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Allstate Prop. & Cas. Ins. Co. v Northeast Anesthesia & Pain Mgt. (2016 NY Slip Op 50828(U))

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.
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Matter of Global Liberty Ins. Co. v Professional Chiropractic Care, P.C. (2016 NY Slip Op 04156)

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.
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NY Rehab Pain Mgt. & Med. Servs., PC v State Farm Auto Ins. Co. (2016 NY Slip Op 50821(U))

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.
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Tyorkin v Garrison Prop. & Cas. Ins. Co. (2016 NY Slip Op 50846(U))

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.
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Matter of GEICO Ins. Co. v AAAMG Leasing Corp. (2016 NY Slip Op 03879)

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.
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Vladenn Med. Supply, Corp. v American Commerce Ins. Co. (2016 NY Slip Op 50775(U))

The main issues in this case were whether the defendant-insurer had met its burden to prove nonappearance at scheduled examinations under oath (EUOs), and whether the defense of failure to appear for EUOs could be asserted regardless of the timeliness of the denial. The court considered the evidence presented by the defendant, which failed to demonstrate personal knowledge of the office procedures when a claimant failed to appear for the EUOs, and noted that the affirmation of defendant's attorney did not state that he was the attorney assigned to conduct the EUOs. The court ultimately decided to affirm the denial of the defendant's motion for summary judgment, as the defendant had failed to meet its burden of proof, and also concluded that the defense of failure to appear for EUOs may be asserted by an insurer regardless of the timeliness of the denial.
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Sutphin Complete Med. Care v Hereford Ins. Co. (2016 NY Slip Op 50763(U))

The court considered the fact that the plaintiff was seeking recovery of assigned first-party no-fault benefits, and that the defendant had properly mailed notices for independent medical examinations (IMEs) to the plaintiff's assignor and his attorney. However, there were triable issues raised as to whether the assignor failed to appear for the scheduled IMEs, which precluded summary judgment for either party. The main issue decided was whether there were triable issues as to whether the assignor failed to appear for the scheduled IMEs, which would preclude an award of summary judgment to either party. The holding of the case was that the action was not ripe for summary disposition, and the court denied the defendant's motion for summary judgment and reinstated the complaint.
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Omega Diagnostic Imaging, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 50762(U))

The court considered the defendant insurer's motion for summary judgment dismissing the complaint in a case involving Omega Diagnostic Imaging, P.C. and Praetorian Insurance Company. The defendant insurance company had timely and properly mailed notices for examinations under oath to the plaintiff's assignor, who failed to appear. However, the court found that the limited record presented triable issues as to whether the assignor's failure to appear was excusable, especially given the assignor's incarceration during the relevant time period. The court ultimately affirmed the order denying the defendant's motion for summary judgment, stating that the defendant's moving submission created rather than eliminated genuine triable issues. The main issue decided was whether the assignor's failure to appear at the examinations under oath was excusable, and the holding of the court was that the issue presented triable issues and therefore the order denying the defendant's motion for summary judgment was affirmed.
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