No-Fault Case Law

The court considered whether the plaintiff was entitled to recover assigned first-party no-fault benefits for claims of medical services rendered. The main issues decided were whether the amounts sought for recovery exceeded the workers' compensation fee schedule and whether the defendant had paid the claims in full. The holding of the case was that the defendant was entitled to summary judgment dismissing claims for services billed under certain codes and for claims where the defendant had not received the claim forms. However, the court granted the plaintiff summary judgement for a claim for services rendered on a specific date and billed under a specific code in the principal sum of $97.14.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, granting the defendant's cross motion for summary judgment dismissing the complaint and denying, as academic, the plaintiff's motion to compel discovery and dismiss the defendant's affirmative defenses in an action to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff had provided the requested verification or had set forth a reasonable justification for the failure to comply with the defendant's verification requests. The holding of the case was that the plaintiff failed to demonstrate that it had provided the requested verification or had set forth a reasonable justification for the failure to comply with the defendant's verification requests, and thus the court found no basis to disturb the order granting the defendant's cross motion for summary judgment and denying the plaintiff's motion. Therefore, the order was affirmed.

The court considered whether a medical provider, Jules Francois Parisien, M.D., as assignee of Nicanor Gonzales, was entitled to recover first-party no-fault benefits from Travelers Insurance Company. The main issue was whether the medical provider failed to appear at duly scheduled examinations under oath (EUOs), and whether the letters sent by the provider demanding an up-front fee and seeking to reschedule the EUOs demonstrated the existence of an issue of fact as to whether the EUOs were scheduled at reasonably convenient times. The court held that the provider's letters demanding a flat up-front fee and seeking to repeatedly reschedule the EUOs to unspecified dates two months later were insufficient to demonstrate the existence of an issue of fact as to whether the EUOs were scheduled at reasonably convenient times, and therefore affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, and denying the plaintiff's cross motion for summary judgment.

The court considered the motion by the defendant to amend the caption and for summary judgment dismissing the complaint on the ground that the plaintiff's assignor had failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided was whether the defendant had twice duly demanded an EUO, that the assignor twice failed to appear, and that defendant issued a timely denial as to each claim after the second failure to appear. The holding of the case was that the order, insofar as appealed from, is affirmed, with $25 costs, as defendant failed to demonstrate that fact as a matter of law concerning the rescheduling of the EUO. As the denials were not timely, an issue of fact remained as to whether defendant's denials were timely and, thus, whether defendant is precluded from interposing its defense that the plaintiff's assignor failed to appear for duly scheduled EUOs.

In this case, Columbus Imaging Center, LLC brought an action to recover first-party no-fault benefits from Nationwide Ins. The main issue in the case was whether or not defendant was entitled to summary judgment dismissing the complaint on the ground that plaintiff's assignor had failed to appear for independent medical examinations (IMEs). Defendant argued that IME scheduling letters had been timely and properly mailed, but the doctors scheduled to perform the IMEs did not establish personal knowledge of the assignor's nonappearance. The court ultimately held that defendant failed to establish its entitlement to judgment since the affidavits from the IME doctors did not support their contention. However, the court also held that plaintiff's cross motion for summary judgment should have been denied as the proof submitted in support of its cross motion failed to establish that the claims had not been timely denied or that defendant had issued timely denial of claim forms. Therefore, the court modified the order by denying plaintiff's cross motion for summary judgment.

The court considered the facts that an insurance company had denied a chiropractic clinic's claim for first-party no-fault benefits on the grounds that the clinic's assignor had failed to appear for scheduled independent medical examinations (IMEs). The main issue decided was whether the insurance company was entitled to partial summary judgment dismissing the second and third causes of action based on the assignor's failure to attend the IMEs. The holding of the case was that the insurance company was entitled to partial summary judgment dismissing the second and third causes of action, as the assignor had failed to comply with a condition precedent to coverage and the insurance company had timely denied the claims on that ground. The court also held that the assignor's denial of receipt of the IME scheduling letters was insufficient to rebut the presumption that the letters were received. Therefore, the insurance company's motion was granted and the order was reversed.

The relevant facts of the case revolve around a motor vehicle accident in 2008, where the plaintiff's car was struck from behind by a sanitation truck. As a result, the plaintiff underwent surgery to remove his L5-S1 disc and replace it with an artificial lumbar disc. The defendant, the plaintiff's insurance company, denied the claim for first-party no-fault benefits on the grounds that the surgery was not medically necessary. The main issue before the court was whether the plaintiff was entitled to recover the first-party no-fault benefits under his insurance policy to cover the cost of his surgery. The court held that the plaintiff made a prima facie showing of entitlement to judgment as a matter of law by submitting evidence that the statutory billing forms were mailed and received, and that the payment of no-fault benefits was overdue. The court also found that the plaintiff had standing to pursue his claims for no-fault benefits and affirmed the judgment in favor of the plaintiff in the principal sum of $44,573.86.

The court considered a case concerning no-fault insurance benefits following a car crash, including the failure of individual claimants to appear for properly-noticed examinations under oath, an allegation that the crash was intentional or staged, and a claim of non-coverage based on the named insured's failure to cooperate with the investigation of the claim. The main issue decided was whether the defaulting defendants' failures constituted a breach of a condition precedent to coverage and whether there was sufficient evidence for entry of a default judgment. The holding of the case was that the plaintiff had established that the failure of the individual claimants to appear for examinations under oath and the intentional/staged nature of the crash warranted a default judgment in favor of the plaintiff, and that the plaintiff had also submitted sufficient evidence warranting a default judgment for the named insured's failure to cooperate with the investigation of the claim.

The court considered the application for default judgment by Unitrin Safeguard Insurance Company against multiple defendants in a no-fault insurance coverage action. The defendants failed to answer or otherwise appear in the case, leading to default judgment being sought. Quality Ortho Complete Joint Care, P.C. filed a cross-motion to dismiss Unitrin's claims against it under CPLR 3215 (c) and CPLR 3211 (a) (4). The main issues before the court were whether Unitrin was entitled to default judgment against the defendants, and whether Quality Ortho's cross-motion to dismiss Unitrin's claims could be granted. The court granted Unitrin's motion for default judgment against the defendants who failed to appear, as there was sufficient evidence of service and founded belief that the claimants' injuries did not arise from a covered collision. The court also granted Quality Ortho's cross-motion to dismiss only to the extent of directing consolidation of this action with a parallel action brought by Unitrin against Quality Ortho, as the first-in-time rule generally governs motions to dismiss under CPLR 3211 (a) (4).

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits, but the defendant argued that the plaintiff's assignor failed to appear for scheduled examinations under oath (EUOs). The main issue decided was whether the defendant had established, prima facie, that the EUO letters were timely and properly mailed, and whether the plaintiff's assignor failed to appear for the scheduled dates. The holding of the court was that the defendant did establish, prima facie, that the EUO letters were timely and properly mailed, and that the plaintiff's assignor did fail to appear on the scheduled dates, thus affirming the order granting the defendant's motion for summary judgment dismissing the complaint.