No-Fault Case Law

The case of Government Employees Insurance Co. v Avanguard Medical Group, PLLC involved a dispute over whether a no-fault insurance carrier was required to pay an office-based surgery (OBS) center for the use of its physical location and related support services. Avanguard Medical Group, PLLC, which is accredited under New York's Public Health Law as an OBS facility, argued that Insurance Law § 5102 required payment for OBS facility fees. The insurance carriers, on the other hand, argued that neither the statute nor regulatory frameworks mandated payment for OBS facility fees. The main issue in the case was whether the no-fault insurance carrier was legally obligated to reimburse Avanguard for OBS facility fees. The Court of Appeals held that the no-fault insurance carrier was not required to reimburse Avanguard for OBS facility fees, as neither the statutory nor regulatory frameworks mandated such payments. This holding was based on the fact that the fee schedules provided reimbursement for professional services delivered in an OBS setting, but did not expressly permit reimbursement for OBS facility fees. The court also noted that the absence of language regarding OBS facility fees in the regulations for hospitals and ambulatory surgery centers suggested that OBS facility fees were not intended to be reimbursed. The court emphasized that the legislature capped total payments for basic economic loss and delegated the determination of fee rates to the Chair and the Superintendent, neither of whom had chosen to include OBS facility fees in the regulatory schedules. Therefore, the court affirmed the Appellate Division's decision that the insurance carrier was not required to reimburse Avanguard for OBS facility fees.

The main issue in this case was whether the petitioner, American Independent Insurance Co. (AIIC), should be allowed to permanently stay arbitration of claims for no-fault benefits under Insurance Law. The Supreme Court had previously determined that the claims were subject to arbitration, but AIIC claimed that it should not have to arbitrate because its policies did not contain an agreement to arbitrate. The court held that AIIC could not be estopped from raising these arguments, as the previous proceeding only concerned personal jurisdiction. Additionally, the court found that the obligation to arbitrate is not found in the policies but is instead imposed by the No-Fault Law. Since AIIC did not have authorization to do business in New York, the insurance company's policies could only satisfy the state's financial security requirements and provide first-party benefits if it was determined that AIIC controlled, was controlled by, or was under common control by, or was with an authorized insurer. As there was insufficient evidence to make that determination, the case was remitted to the Supreme Court for further hearing and a new determination.

The court considered the defendant-insurer's motion for summary judgment dismissing the complaint. The defendant made a prima facie showing of entitlement to judgment as a matter of law by demonstrating that it timely and properly denied the plaintiff's no-fault claim. This was supported by affidavits detailing office mailing procedures and a report of an independent medical examination. The plaintiff's opposition, consisting of an attorney's affirmation unaccompanied by any medical evidence, was deemed insufficient to raise a triable issue as to medical necessity. The court affirmed the order, stating that the plaintiff's specific challenge to defendant's proof of mailing was not properly before the court. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the defendant-insurer's motion for summary judgment dismissing a first-party no-fault action. The defendant's documentary submissions were determined to be sufficient to establish that its denial of claim forms were timely and properly mailed, and that the peer review reports of defendant's chiropractor were in admissible form. However, the copy of a peer review report submitted by the defendant to establish the lack of medical necessity for certain medical supplies was incomplete and insufficient to establish the defense of lack of medical necessity. A medical affidavit submitted by the plaintiff was deemed sufficient to raise a triable issue of fact as to the medical necessity of the medical supplies at issue. As a result, the court reversed the lower court's decision, denied the defendant's motion, and reinstated the complaint. The holding of the court was that the defendant-insurer's motion for summary judgment should have been denied, and the complaint reinstated.

The relevant facts of the case involved a provider seeking to recover first-party no-fault benefits as an assignee, and the defendant's appeal from an order denying their motion seeking summary judgment dismissing the complaint. The main issue decided was whether the motion court had properly exercised its discretion in denying the defendant's motion after the plaintiff had failed to comply with two prior orders to produce its treating provider at a deposition. The court held that the trial court had broad discretion to oversee the discovery process and that the determination of the nature and degree of the penalty to be imposed for failing to comply with an order compelling disclosure lay within the discretion of the motion court. The order denying the defendant's motion was affirmed, without costs.

The court considered the fact that in this action by a provider to recover assigned first-party no-fault benefits, plaintiff's moving papers failed to establish that the defendant had failed to deny the claim within the requisite 30-day period or that the denial was conclusory, vague, or without merit. Defendant, in support of its cross motion, also failed to demonstrate that it is not precluded from asserting the defense of fraudulent procurement of the policy, as defendant failed to establish that it had timely denied plaintiff's claim. To the extent defendant also sought summary judgment on the ground of lack of coverage, a defense which is not subject to preclusion, defendant's proffered evidence was insufficient to establish, as a matter of law, that the assignor's alleged injuries did not arise from an insured incident. The main issue decided was whether plaintiff's motion for summary judgment should be denied and defendant's cross motion for summary judgment dismissing the complaint should be granted. The holding of the case was that defendant's cross motion for summary judgment dismissing the complaint is denied, and the order is affirmed.

The court considered the motion by the defendant to dismiss the complaint by a provider seeking first-party no-fault benefits, on the grounds that the claim was denied due to the plaintiff's assignor failing to appear for scheduled independent medical examinations (IMEs). The main issue decided was whether the defendant's motion to dismiss the complaint should be granted based on the assignor's failure to comply with the IMEs. The court held that the defendant's motion papers did not establish that the letters scheduling the IMEs had been timely mailed, and therefore failed to demonstrate that the IMEs had been properly scheduled. As a result, the court affirmed the order denying the defendant's motion for summary judgment dismissing the complaint.

The court considered the case of Delta Diagnostic Radiology, P.C. as Assignee of NOEL JUNIOR, appealing an order from the Civil Court of New York, which granted the defendant's motion for summary judgment and denied the plaintiff's cross motion for summary judgment. The main issue decided was whether the affidavits submitted by the defendant were sufficient to establish that the plaintiff's assignor had failed to appear for duly scheduled independent medical examinations (IMEs). The holding of the court was that since the assignor's appearance at an IME is a condition precedent to the insurer's liability on the policy, and in opposition to defendant's motion, the plaintiff did not raise a triable issue of fact, the order was affirmed.

The court considered the motion for summary judgment from the defendant, Hartford Insurance Company, in an action to recover assigned first-party no-fault benefits. The main issue was whether the defendant was the proper insurer for the claim. The defendant claimed it was not the proper insurer for the assignor's employer for no-fault claims, but the court found that the evidence provided was not sufficient to establish this for summary judgment. The court also denied the plaintiff's cross-motion for summary judgment and granted the plaintiff's motion to compel discovery, as the plaintiff contended that discovery was not complete. The holding of the case was that the defendant's motion for summary judgment was denied, the plaintiff's cross-motion for summary judgment was denied, and the plaintiff's motion to compel discovery was granted.

The relevant facts considered by the court were that the plaintiff, Big Apple Ortho Products, Inc., was seeking to recover first-party no-fault benefits that had been denied by the defendant, State Farm Mutual Automobile Ins. Co., on the basis that the accident in question occurred in Georgia and therefore was not covered by New York State no-fault law. The defendant provided an affidavit from a claims representative and a police report to support their argument. The main issue decided by the court was whether the accident fell under the coverage provided by New York State no-fault law, given the location of the accident and the residency of the individual involved. The holding of the court was that the defendant's motion for summary judgment was denied without prejudice, as the evidence presented was found to be inadmissible and did not establish whether the individual involved was a New York State resident or if he was covered by another policy providing the required coverage.