No-Fault Case Law

The court considered the fact that the defendant's claims adjuster's affidavit established that the defendant did not receive the claims at issue. However, the affidavit by the plaintiff's billing manager demonstrated that the claim forms had been mailed to the defendant, leading to an issue of fact as to whether the defendant's time to pay or deny these claims ever began to run. The main issue decided was whether the defendant had received the claims at issue and whether their time to pay or deny the claims had begun. The holding of the case was that there was an issue of fact as to whether the defendant's time to pay or deny the claims ever began to run, and the Civil Court properly denied the defendant's motion for summary judgment dismissing the complaint.

The relevant facts the court considered were that Compas Medical, P.C., as assignee of Mitchelle Paul, brought an action to recover assigned first-party no-fault benefits from Praetorian Ins. Co. Plaintiff moved for summary judgment, which was denied by the Civil Court. The court granted defendant's cross motion for summary judgment dismissing the complaint, as plaintiff had failed to provide requested verification and failed to comply with a condition precedent to coverage. Plaintiff's assignor also failed to appear for independent medical examinations and examinations under oath. The main issue decided was whether plaintiff had provided the requested verification and complied with the conditions precedent to coverage, and whether the assignor had failed to attend scheduled examinations. The holding of the case was that the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment dismissing the complaint was affirmed.

The Court considered the issue of whether the denial of claim forms at issue were untimely, and if the defendant had established its entitlement to summary judgment by sending timely examination under oath (EUO) scheduling letters to the plaintiff. The main issue was whether the defendant had failed to establish its entitlement to summary judgment by failing to demonstrate that it had tolled its time to pay or deny the claims at issue by sending timely examination under oath scheduling letters to the plaintiff. The Court held that the EUO scheduling letters annexed in support of defendant's motion did not include the necessary information to establish as a matter of law that it had tolled its time to pay or deny the claims at issue, and therefore the motion for summary judgment was denied.

The relevant facts considered by the court were that the plaintiff, Ultimate Health Products, Inc., was seeking to recover first-party no-fault benefits as the assignee of Seraphin Pierre. The main issue decided was whether the defendant, American Transit Insurance Company, had timely and properly denied the claims based on the assignor's failure to appear for examinations under oath (EUOs). The court held that the defendant had established that the EUO scheduling letters had been timely mailed, and therefore affirmed the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint.

The relevant facts considered by the court were that Compas Medical, P.C. filed a motion for summary judgment to recover first-party no-fault benefits. The court granted the defendant's cross motion for summary judgment dismissing the claims. The main issues decided were whether the defendant had timely mailed verification requests and scheduling letters for an independent medical examination and examination under oath, and whether the plaintiff's assignor had failed to appear for the scheduled appointments. The holding of the case was that the defendant had timely mailed the verification requests and scheduling letters, and the plaintiff's assignor had failed to appear for the scheduled appointments, therefore entitling the defendant to summary judgment dismissing the claims. The court affirmed the order in favor of the defendant.

The relevant facts considered by the court were that the plaintiff, a medical provider, was seeking to recover assigned first-party no-fault benefits from the defendant, an insurance company. The defendant moved for summary judgment dismissing the complaint, claiming that the medical services at issue were not medically necessary. The main issue decided by the court was whether the defendant was entitled to summary judgment dismissing the complaint. The court held that the defendant's motion for summary judgment dismissing the complaint was granted, as the plaintiff failed to provide sworn or signed letters of medical necessity to rebut the defendant's prima facie showing that the services were not medically necessary. Therefore, the defendant was entitled to judgment.

The court considered the motion for summary judgment by the defendant to dismiss the complaint, which was based on the plaintiff's failure to appear for scheduled examinations under oath (EUOs). The main issue decided was whether the defendant had timely and properly denied the claims at issue due to the plaintiff's nonappearance for the EUOs. The court held that the defendant's motion was properly denied because it failed to submit proof by someone with personal knowledge of the plaintiff's nonappearance for the EUOs in question. The order denying the defendant's motion for summary judgment was affirmed by the court.

The main issue in this case was whether the defendant failed to make a prima facie showing of lack of medical necessity for acupuncture services provided. The court considered the affirmed independent medical examination (IME) report from the doctor who had performed the IME, as well as the IME reports and accompanying affidavits executed by the chiropractor and acupuncturist who had also performed IMEs, which set forth a factual basis and a medical rationale for the IME providers' determinations that there was no medical necessity for the acupuncture services at issue. The court ultimately held that the defendant's cross motion was properly granted, as the plaintiff's arguments lacked merit, and the affidavit by an acupuncturist submitted by the plaintiff failed to meaningfully refer to or rebut the conclusions of the IME doctors. Therefore, the court affirmed the order, dismissing the complaint insofar as it sought to recover upon claims for dates of service May 21, 2008 through July 31, 2008.

The court considered the motion for summary judgment brought by the plaintiff, a no-fault insurer, to declare that its policy does not provide coverage to the individual defendant for a specific accident due to her failure to appear for scheduled examinations under oath (EUO). The defendants argued that the plaintiff had not established that it had requested the EUO within the time frame set by the no-fault regulations. In response, the plaintiff failed to supply evidence bearing on whether the EUO had been requested within the appropriate time frame. The main issue decided by the court was whether the plaintiff had properly requested the EUO within the time frame set by the no-fault regulations in order to deny coverage. The holding of the case was that the plaintiff's motion for summary judgment was properly denied because it failed to supply evidence showing that the EUO had been requested within the appropriate time frame.

The main issue in American Tr. Ins. Co. v Vance was whether defendant KHL Acupuncture, P.C. was entitled to receive no-fault benefits from the plaintiff. The court considered the fact that KHL's assignor, Shateahah Vance, did not appear for scheduled independent medical examinations (IMEs). The court held that the plaintiff failed to establish that it was entitled to deny KHL's claim because the scheduling of the IMEs did not comply with the procedures and time frames set forth in the No-Fault implementing regulations. The court reversed the lower court's decision, denied the plaintiff's motion for summary judgment, and vacated the declaration that KHL was not entitled to receive no-fault benefits. In a dissenting opinion, Judge Friedman disagreed with the reversal of summary judgment, arguing that the issue of whether the IMEs were scheduled to be held within the 30-day time frame prescribed by Insurance Department Regulations was raised for the first time on appeal. Judge Friedman suggested that if the issue had been raised before the motion court, the plaintiff may have been able to establish that the IMEs had been scheduled in compliance with the regulation. Furthermore, he stated that it seemed unfair to reverse the motion court's decision based on an issue that was not raised in the defendant's opposition to the motion.