No-Fault Case Law

The court considered whether a provider was entitled to recover first-party no-fault benefits, and whether the insurance company had properly paid for the services at issue according to the workers' compensation fee schedule. The main issue was whether the denial of the claim form had been timely mailed and if the insurance company had fully paid the provider for the services at issue. The court held that the insurance company had established that the denial of the claim form had been timely mailed, and that it had fully paid the provider for the services at issue in accordance with the workers' compensation fee schedule. The court declined to consider the provider's remaining contention, as it was being raised for the first time on appeal, and affirmed the lower court's decision.

The court considered the motion for summary judgment by the plaintiff and the cross motion for summary judgment by the defendant in a case involving a provider seeking to recover assigned first-party no-fault benefits. The main issue decided was whether there was coverage for the no-fault benefits as the defendant had not issued an automobile insurance policy which would cover the underlying accident. The court held that the lack of coverage defense could be raised without regard to the timeliness of an insurer's denial of claim form, and that the defendant had established that the policy being sued upon was a workers' compensation insurance policy which did not cover the plaintiff's claim. As the plaintiff failed to demonstrate the existence of an applicable automobile insurance policy or raise a triable issue of fact, the court affirmed the denial of the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered the fact that plaintiff, Delta Diagnostic Radiology, P.C., was seeking to recover first-party no-fault benefits as the assignee of YVAN PLETEAU. Plaintiff moved for summary judgment, while defendant cross-moved for summary judgment dismissing the complaint on the basis that the claims were denied due to the assignor's failure to appear for examinations under oath (EUOs). The main issue decided was whether the defendant had timely and properly denied the claims based on the assignor's failure to appear for EUOs. The court held that the defendant had established that the EUO scheduling letters had been timely mailed and that the assignor failed to appear for the scheduled EUOs, demonstrating a failure to comply with a condition precedent to coverage. As a result, the defendant was entitled to summary judgment dismissing the complaint, and the order was affirmed.

Issue: The main issue in the case is whether the defendant, an assignee of first-party no-fault benefits, is entitled to no-fault benefits from the plaintiffs with respect to the no-fault claims at issue in the action. Facts: The plaintiffs allege that the defendant submitted claims for medical services that they provided to occupants of insured automobiles, with concerns of fraudulent practices. The investigation revealed that the defendant was engaging in upcoding of claims and the owner of the medical practice had previously been disciplined by the New York State Office of Professional Medical Conduct for fraudulent practices. Decision: The court held that the defendant's failure to answer all relevant questions at the Examination Under Oath (EUO), as required by the insurance policies, constitutes a material breach of contract and precludes recovery by the defendant. Therefore, it was determined that the defendant was not entitled to no-fault benefits in this case.

The relevant facts considered in the case were that New Way Acupuncture, P.C., as assignee of Igor Kris, was seeking to recover first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue was whether defendant's delay in payment letters tolled the statutory time period within which it was required to pay or deny the claims at issue. The holding of the case was that the branches of defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon the unpaid portions of claims for $2,015 and $985 were denied, as the delay letters did not toll the statutory time period and defendant failed to establish as a matter of law that it was not precluded from raising its defense that the fees sought exceeded the amount permitted by the workers' compensation fee schedule. Plaintiff's cross motion also failed to establish that defendant had failed to pay or deny the claims within the requisite 30-day period, and thus the plaintiff failed to demonstrate its entitlement to summary judgment.

The relevant facts considered by the court in this case were that Compas Medical, P.C. sought to recover assigned first-party no-fault benefits from Farm Family Casualty Ins. Co. The main issues decided by the court were whether the claim forms had been properly mailed to the insurance company and whether the insurance company had failed to pay or deny the claims within the required time period. The holding of the case was that the branches of the insurance company's cross motion seeking summary judgment to dismiss the first and third causes of action were denied, and the order was affirmed, without costs. The court found that there was an issue of fact as to whether the insurance company's time to pay or deny the claims had begun to run, and that the insurance company failed to submit sufficient proof to dismiss the first and third causes of action.

The court considered a motion for summary judgment by the plaintiff to recover assigned first-party no-fault benefits and a cross-motion by the defendant to dismiss the complaint on the basis of fraudulent procurement of the insurance policy and that the amount sought to be recovered exceeded the amount permitted by the workers' compensation fee schedule. The main issue decided was whether the defendant had established its defense of fraudulent procurement of the insurance policy. The holding was that the branch of defendant's cross-motion seeking summary judgment dismissing the complaint on the ground of fraudulent procurement of the insurance policy was denied, and the matter was remitted to the Civil Court for a determination of the branch of defendant's cross-motion seeking summary judgment dismissing the complaint on the ground that the amount sought to be recovered exceeded the amount permitted by the workers' compensation fee schedule.

The relevant facts of the case included a provider seeking to recover assigned first-party no-fault benefits, and plaintiff's motion for summary judgment, and defendant's cross motion for summary judgment dismissing the complaint. The issues decided were whether the first cause of action was premature due to failure to provide requested verification, and whether the failure of plaintiff's assignor to appear for independent medical examinations and examinations under oath justified summary judgment dismissing the claims. The holding was that defendant's cross motion seeking summary judgment dismissing the first cause of action was denied due to a triable issue of fact as to whether the cause of action was premature, and defendant was entitled to summary judgment dismissing the second through sixth causes of action due to plaintiff's assignor failing to comply with a condition precedent to coverage.

The relevant facts the court considered were that GL Acupuncture, P.C. had moved for summary judgment to recover assigned first-party no-fault benefits, but Praetorian Ins. Co. had cross-moved for summary judgment dismissing the complaint, arguing that they had properly paid GL Acupuncture, P.C. for the services at issue in accordance with the workers' compensation fee schedule. The main issue decided was whether Praetorian Ins. Co. had properly paid GL Acupuncture, P.C. for the services at issue in accordance with the fee schedule. The court held that Praetorian Ins. Co. had established that they had timely mailed the denial of claim form and had fully paid GL Acupuncture, P.C. for the services at issue in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors, therefore affirming the order.

The court considered the plaintiff's motion for summary judgment and the defendant's cross-motion for summary judgment, as well as issues related to the timely mailing of independent medical examination (IME) and examination under oath (EUO) scheduling letters, the failure of plaintiff's assignor to appear for scheduled IMEs and EUOs, and the timely denial of claims by the defendant. The court also considered the issue of medical necessity of the services at issue in the plaintiff's seventh and eighth causes of action. The main issues decided were whether the defendant had demonstrated that the plaintiff's assignor failed to comply with a condition precedent to coverage, and whether there were triable issues of fact regarding the medical necessity of the services in the seventh and eighth causes of action. The holding was that the defendant was entitled to summary judgment dismissing the first through sixth causes of action, and that there were triable issues of fact regarding the medical necessity of the services in the seventh and eighth causes of action.