No-Fault Case Law

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.

The court considered an appeal from an order of the District Court which denied the defendant's motion for summary judgment in a case where a medical care provider was seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided by the court was whether the insurance policy had been effectively terminated, as the defendant claimed, and whether this termination was effective with respect to the plaintiff's assignor. The court held that the defendant failed to sufficiently demonstrate that it had filed a copy of the notice of termination of the insurance policy with the Department of Motor Vehicles within 30 days of the effective date of the termination, as required by Vehicle and Traffic Law, and therefore the termination was not effective with respect to the plaintiff's assignor. Consequently, the defendant's motion for summary judgment dismissing the complaint was properly denied and the order was affirmed.

The main issues in the case were whether the defendant, 21st Century Insurance, acted negligently in denying the plaintiff, Michael Bertucci's, claim for no-fault benefits and whether punitive damages were warranted. The court considered the plaintiff's claim that his medical treatment was delayed due to the defendant's non-payment of his medical bills, resulting in the aggravation and exacerbation of his injuries. The court also considered the defendant's argument that it had no legal duty to refrain from communicating with the plaintiff's health care providers regarding its intentions to not pay submitted bills. The holding of the case was that the defendant's motion to dismiss the plaintiff's first cause of action was granted, as the plaintiff failed to specify or identify the duty that the defendant allegedly breached. Additionally, the claim for punitive damages in the plaintiff's second cause of action was dismissed, as the defendant's conduct did not constitute a tort independent of the insurance contract itself.

The relevant facts of the case were that plaintiff brought an action to recover no-fault benefits for services rendered to its assignor, who allegedly sustained injuries in a motor vehicle accident. Defendant had also commenced a declaratory judgment action against the plaintiff's assignor and other providers, seeking a declaration that they were not entitled to no-fault benefits due to the assignor's failure to comply with the terms of the insurance policy. Plaintiff and the assignor did not appear or serve an answer in the declaratory judgment action. Defendant then moved for summary judgment dismissing the complaint in this action, based on the assignor's failure to appear at scheduled examinations under oath (EUOs). The court held that the action was barred under the doctrine of res judicata, as a decision in favor of the defendant had been made in the declaratory judgment action, and affirmed the order granting defendant's cross-motion for summary judgment dismissing the complaint.