No-Fault Case Law

The court considered the fact that the plaintiff, a provider seeking to recover first-party no-fault benefits, failed to oppose the defendant's motion for summary judgment dismissing the complaint on the ground of lack of medical necessity. The Civil Court had granted the defendant's motion on default and dismissed the complaint with prejudice. The main issue was whether the plaintiff's claim of law office failure constituted a reasonable excuse for the default under CPLR 5015(a). The holding of the court was that the Civil Court did not improvidently exercise its discretion in denying the plaintiff's motion, as the claim of law office failure was conclusory and unsubstantiated, and did not constitute a reasonable excuse for the default. Therefore, the order denying the plaintiff's motion was affirmed.

The relevant facts the court considered in this case were that Lenox Hill Radiology and Mia, P.C. (doing business as Regency Medical Imaging) sought to recover assigned first-party no-fault benefits from Great Northern Insurance Company. Great Northern Insurance Company appealed an order of the District Court that denied its motion for summary judgment dismissing the complaint. The main issue decided was whether there was a triable issue of fact as to the submission of the claim form, as defendant claimed it had not received the form, while the affidavit of the mailing supervisor in plaintiff's attorneys' offices established that the claim at issue had been mailed to defendant. The holding of the case was that the Appellate Term affirmed the order, without costs, as there was a triable issue of fact as to the submission of the claim form, and untimely submission in and of itself does not entitle defendant to summary judgment dismissing the complaint.

The relevant facts the court considered involved a provider seeking to recover no-fault benefits from an insurance company, with the insurance company arguing that the provider failed to establish its entitlement to judgment as a matter of law. The main issues decided by the court were whether the provider made a prima facie showing of entitlement to summary judgment and whether the insurance company had established proof of its defenses against the claims. The holding of the case was that the provider did make a prima facie showing, while the insurance company failed to raise a triable issue of fact. Therefore, the court reversed the lower court's order and granted the provider's motion for summary judgment.

The court considered the appeal made by the defendant-insurer from an order of the Civil Court of the City of New York denying its motion for summary judgment dismissing the complaint by EMA Acupuncture, P.C. The main issue decided was whether the defendant had made a prima facie showing of entitlement to summary judgment. The court held that the denial of the defendant-insurer's motion for summary judgment was sustained, as they failed to provide any evidence from someone with personal knowledge of the plaintiff's nonappearances at scheduled examinations under oath. The court determined that the affirmation of the defendant's attorney did not demonstrate personal knowledge of the office procedures when a claimant failed to appear for an examination under oath, and therefore the defendant's motion for summary judgment was denied.

The relevant facts in the case are that defendant issued a commercial general liability insurance policy to plaintiff, a construction firm, effective from October 2008 to October 2009. Plaintiff was the general contractor at a construction site where Allan Speirs was injured in the course of his work for a subcontractor in February 2009. In August 2011, Speirs commenced an action against plaintiff and the owner of the construction site. However, plaintiff was not made aware of the personal injury action until counsel for Speirs alerted defendant to that fact in March 2012. Defendant disclaimed coverage because plaintiff failed to give notice of the personal injury action as required by the liability policy. The main issue was whether defendant had a duty to defend and/or indemnify plaintiff in the underlying action. The holding of the case was that the absence of timely notice of the personal injury lawsuit was unreasonable as a matter of law, and that defendant had no duty to defend or indemnify plaintiff in the underlying action, as plaintiff failed to provide timely notice of the personal injury action.

The relevant facts considered by the court were that Pugsley Chiropractic PLLC filed a lawsuit against Merchants Preferred Ins. Co. for a first-party no-fault action, based on lack of medical necessity. The main issue decided in the case was whether the independent medical examination (IME) report of defendant's chiropractor/acupuncturist, Antoinette Perrie, was admissible as evidence. The court held that the IME report of Dr. Perrie was not admissible as it erroneously identified her as a licensed "physician" and was denominated as an affirmation purportedly made under the authority of CPLR 2106, which neither a chiropractor nor an acupuncturist may do. Additionally, the court also held that Pugsley Chiropractic PLLC's cross motion for summary judgment was properly denied, as it failed to establish prima facie that its claims were overdue within the prescribed 30-day period. Therefore, the court modified the order to deny the defendant's motion for summary judgment and reinstate the complaint.

The plaintiff, AutoOne Insurance/General Assurance, appealed a decision in which they moved for summary judgment on their complaint that they should not have to pay certain no-fault insurance claims submitted by the defendant, Eastern Island Medical Care. Juana Coyotl had been injured in an automobile accident and Eastern Island Medical Care was billing AutoOne, the plaintiff, for treating her subsequent injuries. AutoOne claimed that the treatment was not medically necessary and denied the claim. The defendant, however, raised an argument that there was a triable issue of fact with regards to the medical necessity and submitted affidavits and medical records on Coyotl's treatment which were sufficient to raise such an issue. The Supreme Court stated that further proceedings were required to determine the issue of the medical necessity of the treatment rendered to Coyotl. The Appellate Division upheld the Supreme Court's decision insofar as it was appealed from, and required further proceedings to determine whether the treatments rendered could be considered valid.

The court considered the plaintiff's claim for recovery of no-fault benefits for medical services provided, which the defendant denied payment for due to alleged over-billing. The main issue decided was whether recent amendments to the regulations required the plaintiff to prove billing in accordance with the fee schedule in order to make its case for entitlement to reimbursement. The holding of the court was that the burden remained on the defendant to assert a defense that the provider billed in excess of the fee schedule, and the recent amendments did not change the plaintiff's prima facie burden. The court also found that the defendant's evidence supported its calculations and payments to the plaintiff in accordance with the fee schedule, and therefore the defendant's motion for summary judgment was granted and the plaintiff's complaint was dismissed.

The case involves Natural Therapy Acupuncture, P.C. seeking to recover no-fault benefits for medical services provided to its assignor after an automobile accident. Another insurance company, Kemper Independence Insurance Company, had previously filed a declaratory judgment action against Natural Therapy and other providers, which resulted in an order declaring that Kemper had no duty to pay no-fault benefits to the named providers. Natural Therapy then filed a motion for summary judgment, and defendant cross-moved for summary judgment arguing that the action was barred by the order in the declaratory judgment action. The court considered whether the instant action was barred by the order in the declaratory judgment action. It was decided that the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment was affirmed, as there was no coverage for the accident in question based on the order in the declaratory judgment action.

The relevant facts considered by the court were that EMC Health Products, Inc. was seeking to recover assigned first-party no-fault benefits from National Liability & Fire Insurance Company. The main issue decided was whether the causes of action in the complaint were premature because EMC Health Products, Inc. had failed to provide requested additional verification. The holding of the court was that there was a triable issue of fact as to whether the causes of action were premature, based on an affidavit submitted by EMC Health Products, Inc. In light of this, the court affirmed the order of the Civil Court, denying the branches of the defendant's cross motion seeking summary judgment dismissing the first, second, third, and fifth causes of action of the complaint.