No-Fault Case Law
Encompass Ins. Co. v Rockaway Family Med. Care, P.C. (2016 NY Slip Op 01921)
March 17, 2016
The court in this case considered a motion for de novo review of a master arbitrator's findings and summary judgment by the plaintiff. The main issue decided was whether the plaintiff satisfied the requirements for a de novo adjudication of the dispute under Insurance Law §5106 (c). The holding of the court was that the plaintiff was entitled to a de novo review of the arbitrator's findings and an extension of time to send its second follow-up request for an examination under oath, based on General Construction Law §25-a. The court modified the lower court's decision to reinstate the complaint and grant the part of the motion seeking de novo review of the arbitrator's findings and affirmed the decision without costs.
Meridian Psychological Servs., P.C. v Allstate Ins. Co. (2016 NY Slip Op 50375(U))
March 16, 2016
The relevant facts considered by the court in Meridian Psychological Services, P.C. v Allstate Insurance Company included a nonjury trial of the action by a provider to recover assigned first-party no-fault benefits. The main issues decided in this case were the timeliness and proper mailing of defendant's letters scheduling examinations under oath (EUOs) and the proof that plaintiff's assignor had failed to appear for the EUOs. The holding of the court was that the defendant failed to establish that the EUO scheduling letters had been timely and properly mailed to plaintiff's assignor, and that the defendant also failed to prove that plaintiff's assignor had failed to appear for the two duly scheduled EUOs. As a result, the judgment awarding the plaintiff the principal sum of $1,365.21 was affirmed.
Great Health Care Chiropractic, P.C. v Unitrin Direct Ins. Co. (2016 NY Slip Op 50373(U))
March 16, 2016
The main issue in this case was whether the defendant was entitled to summary judgment dismissing the complaint filed by the plaintiff, who sought to recover assigned first-party no-fault benefits. The court considered whether the defendant had timely denied the claim in question and whether the plaintiff had demonstrated its entitlement to summary judgment. The court held that the defendant's motion for summary judgment dismissing the complaint was denied, as the defendant had failed to establish its entitlement to judgment as a matter of law. However, the court also held that the plaintiff had also failed to demonstrate its entitlement to summary judgment, as it did not establish that the claim had not been timely denied or that the defendant had issued a timely denial of the claim. Therefore, the court modified the order to deny the defendant's motion for summary judgment.
New Way Med. Supply Corp. v American Tr. Ins. Co. (2016 NY Slip Op 50370(U))
March 16, 2016
The relevant facts the court considered were related to a dispute between New Way Medical Supply Corp. and American Transit Insurance Co. regarding the payment of first-party no-fault benefits. The main issue decided was whether the plaintiff had failed to comply with a condition precedent to coverage by not appearing for scheduled examinations under oath (EUOs). The holding of the court was that the defendant had timely mailed the EUO scheduling letters and the plaintiff's assignor had failed to appear for the scheduled EUOs, thus failing to comply with a condition precedent to coverage. As a result, the defendant was entitled to summary judgment dismissing the complaint. The court affirmed the order, with the plaintiff having to pay $25 in costs.
Tam Med. Supply Corp. v American Tr. Ins. Co. (2016 NY Slip Op 50369(U))
March 16, 2016
The relevant facts in this case were that Tam Medical Supply Corp., as assignee of DOR GUY MARCEL, appealed from an order of the Civil Court of the City of New York, Queens County, which denied plaintiff's motion for summary judgment and granted defendant's cross motion for summary judgment dismissing the complaint. The main issue decided by the court was whether the action by the provider to recover assigned first-party no-fault benefits was premature due to the failure to provide requested verification. The holding of the court was that there is a triable issue of fact as to whether the action is premature because plaintiff had submitted an affidavit from the owner, which was sufficient to give rise to a presumption that the requested verification had been mailed to and received by defendant. Therefore, the court modified the order by providing that defendant's cross motion for summary judgment dismissing the complaint is denied.
Ultimate Health Prods., Inc. v Hereford Ins. Co. (2016 NY Slip Op 50367(U))
March 16, 2016
The relevant facts considered by the court in the case of Ultimate Health Prods., Inc. v Hereford Ins. Co. were that the plaintiff was seeking to recover first-party no-fault benefits as the assignee of an individual named Paul Luckner. The main issue decided in the case was whether the defendant, Hereford Insurance Co., had issued an automobile insurance policy covering the underlying accident. The court held that the defendant had established that there was no coverage for no-fault benefits because the policy being sued upon was a workers' compensation insurance policy which did not cover the plaintiff's claim for reimbursement of assigned first-party no-fault benefits. Therefore, the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint was affirmed.
Performance Plus Med., P.C. v Nationwide Ins. (2016 NY Slip Op 50366(U))
March 16, 2016
The court considered the appeal of Performance Plus Medical, P.C. from an order of the Civil Court of the City of New York, Kings County that granted defendant's motion for summary judgment dismissing the complaint. The main issues decided were whether the insurer's time to pay or deny a claim is tolled when a timely verification request has been provided, and whether the defendant had properly denied the claims for the services at issue. The holding of the court was that the insurer's time to pay or deny the entire claim is tolled if the provider has failed to respond to a request for verification, and that the defendant had established prima facie entitlement to summary judgment dismissing the second through tenth causes of action, as well as dismissing the first cause of action pursuant to the workers' compensation fee schedule. Therefore, the court affirmed the order of the Civil Court.
Matter of Singh v Allstate Ins. Co. (2016 NY Slip Op 01855)
March 16, 2016
The court considered a petition to vacate master arbitration awards that had denied the petitioner's no-fault claims for lost wages following an automobile accident. The petitioner appealed after the master arbitration awards were confirmed by a lower court. The main issue was whether there were sufficient grounds to vacate the master arbitration awards. The court held that the public policy in favor of arbitration meant that the grounds specified in CPLR 7511 for vacating or modifying a no-fault arbitration award were few and narrowly applied. In this case, the petitioner failed to demonstrate any ground for vacating the master arbitration awards, and the determinations of the master arbitrator were found to have evidentiary support and a rational basis. Therefore, the court affirmed the lower court's decision to deny the petition and confirm the master arbitration awards.
Ultimate Health Prods., Inc. v American Tr. Ins. Co. (2016 NY Slip Op 50330(U))
March 15, 2016
The main issue in this case was whether the insurance company had properly denied a claim for first-party no-fault benefits based on the plaintiff's assignor's failure to appear for examinations under oath (EUOs). The court held that the insurance company had timely mailed the EUO scheduling letters and that the plaintiff's assignor had failed to comply with the scheduled EUOs. Since the insurance company had timely denied the claim on the ground of the assignor's failure to appear for the EUOs, they had demonstrated that the assignor failed to comply with a condition precedent to coverage. The court denied the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment dismissing the complaint. Therefore, the order was affirmed.
GBI Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 50329(U))
March 15, 2016
The main issue in this case was whether State Farm Mutual Automobile Insurance Co. had properly used the workers' compensation fee schedule applicable to chiropractors who render the same services as acupuncturists to reimburse GBI Acupuncture, P.C. for the acupuncture services it had rendered. The court considered the argument from GBI Acupuncture, P.C. that State Farm failed to establish that its fee schedule reductions were proper. However, the court disagreed with GBI Acupuncture, P.C. and found that State Farm had demonstrated that it had fully paid GBI Acupuncture, P.C. for the services at issue in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. As a result, the court affirmed the order granting State Farm's motion for summary judgment dismissing the complaint.