No-Fault Case Law

In this case, a provider, Great Health Care Chiropractic, P.C., sought to recover no-fault benefits for services rendered to its assignor following a motor vehicle accident. However, defendant Progressive Insurance Company moved to consolidate the present action with two other actions and for summary judgment dismissing the complaint in each of the three actions, arguing that they were barred by a default judgment in a Supreme Court declaratory judgment action. The Supreme Court declared that the plaintiff and other providers were not entitled to recover no-fault benefits in a judgment entered on default. As a result, the present action is barred under the doctrine of res judicata, and any judgment in favor of the plaintiff in the present action would impair the rights or interests established by the Supreme Court judgment. The Court held that the declaratory judgment was a conclusive final determination, and the order granting the defendant’s motion for summary judgment dismissing the complaint in the present action was affirmed.

The court considered the issue of whether there was a lack of medical necessity for the services provided in a first-party no-fault benefits claim. The defendant submitted two independent medical examination reports, one from a chiropractor and one from an orthopedist, which concluded that there was a lack of medical necessity for the services. However, the medical affidavits submitted by the plaintiffs in opposition were deemed sufficient to raise a triable issue of fact as to the medical necessity of the claims at issue. Ultimately, the court reversed the order and denied the branches of the defendant's motion seeking summary judgment dismissing the plaintiffs' first through eighteenth and twenty-first through thirty-sixth causes of action. Therefore, the holding of the case was in favor of the plaintiffs, allowing their claims to proceed to trial.

The relevant facts the court considered in this case were that the defendant's motion for summary judgment dismissing the plaintiff's complaint was denied by the District Court. The main issue decided was whether the defendant had established its prima facie entitlement to summary judgment. The holding of the case was that defendant's motion for summary judgment dismissing the complaint should have been granted, as the plaintiff failed to submit medical evidence sufficient to raise a triable issue of fact as to medical necessity, and the opposing affirmation of plaintiff's doctor failed to rebut the conclusions set forth in the IME report. Therefore, the order denying the defendant's motion was reversed, and defendant's motion for summary judgment dismissing the complaint was granted.

The relevant facts considered by the court were that the plaintiff, Healthy Way Acupuncture, P.C., filed a lawsuit to recover assigned first-party no-fault benefits from the defendant, State Farm Mutual Automobile Ins. Co. The defendant moved for summary judgment to dismiss the complaint, citing the plaintiff's failure to appear for duly scheduled examinations under oath, with supporting affirmation from their law firm. The plaintiff also cross-moved to disqualify the defendant's law firm, claiming that a member of the firm was a necessary witness in the case. The main issue decided by the court was whether the plaintiff's failure to appear for scheduled examinations under oath provided grounds for the defendant's motion for summary judgment. The court ultimately affirmed the order, granting the defendant's motion for summary judgment and implicitly denying the plaintiff's cross motion to disqualify the defendant's law firm. The holding of the case was in favor of the defendant, State Farm Mutual Automobile Ins. Co., with the order being affirmed by the court.

In this case, GBI Acupuncture, P.C. sought to recover first-party no-fault benefits for services provided to its assignor, who was injured in a motor vehicle accident. However, Nationwide Insurance had previously obtained a default judgment from the Supreme Court stating that it was not obligated to provide no-fault benefits to the plaintiff and its assignor. When the case was brought to the Civil Court, Nationwide moved to dismiss the complaint, arguing that the previous Supreme Court order barred the current action under the doctrines of res judicata and collateral estoppel. The Civil Court granted Nationwide's motion to dismiss, holding that the current action was indeed barred by the previous Supreme Court order. The decision was affirmed by the Appellate Term, Second Department on July 7, 2015. The main issue that was decided in this case was whether the current action seeking first-party no-fault benefits was barred by the previous order from the Supreme Court, and the holding was that it was indeed barred under the doctrine of res judicata.

The court considered a motion by a provider to recover assigned first-party no-fault benefits and a motion by the defendant to dismiss the complaint on the ground of lack of medical necessity. The defendant moved for summary judgment based on a peer review, and the plaintiff moved to compel disclosure or for alternative relief in response. The main issue decided was whether there was a legitimate need for discovery to respond to the defendant's summary judgment motion, and the holding of the case was that the court affirmed the order granting the plaintiff's motion to compel disclosure, with costs. The court found that the Civil Court did not improvidently exercise its discretion in finding a legitimate need for discovery to respond to the defendant's summary judgment motion, and therefore properly granted the motion to compel disclosure.

The relevant facts the court considered were that the plaintiff, a provider seeking first-party no-fault benefits, appealed from an order of the Civil Court that granted the defendant insurance company's motion for summary judgment dismissing the complaint. The defendant's motion was based on the plaintiff's assignor failing to appear for scheduled independent medical examinations (IMEs). The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint. The court held that while the plaintiff's cross motion for summary judgment was properly denied, the defendant's motion for summary judgment dismissing the complaint should also have been denied because the defendant failed to establish its entitlement as a matter of law to the dismissal of the complaint. Therefore, the order was modified to provide that the defendant's motion for summary judgment dismissing the complaint is denied.

The main issue in this case was whether Liberty Mutual Insurance Company and other appellants were obligated to pay defendant, Five Boro Medical Equipment, Inc., for submitted claims. Plaintiffs, who are no-fault automobile insurers in New York State, suspected that defendant was over-billing them for medical equipment and requested an examination under oath (EUO) to verify the billings. When defendant failed to appear for the scheduled EUOs, plaintiffs commenced a declaratory judgment action and moved for a default judgment. However, the IAS court denied the motion on the grounds that plaintiffs had not submitted sufficient proof of mailing the letters notifying defendant of the scheduled EUOs. The Appellate Division reversed this decision, holding that the affirmation of plaintiffs' counsel adequately set forth the mailing procedures and constituted sufficient proof that the EUO letters were mailed to defendant. As a result, it was declared that plaintiffs were not obligated to pay defendant for the claims at issue.

The Court is deciding on the dismissal of the claim for no-fault benefits, which involves the issue of whether a plaintiff may offer an NF-10 denial of claim form into evidence to prove that it mailed the subject claim form and that the insurer received it. The court considers various precedents, including the recent Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. The Court affirms that a plaintiff no-fault provider can establish its prima facie entitlement to judgment by successfully submitting proper evidentiary proof that it generated and mailed the prescribed statutory billing forms to the defendant insurer and that the no-fault benefits were overdue. The holding is that a plaintiff medical provider must submit proof of mailing through evidence in admissible form, which evidence may include the verification of treatment form and/or an affidavit from a person knowledgeable of the claim and how it was sent to the insurer.

The court considered a case where the petitioner, a passenger named Fitzgerald, sought Supplementary Uninsured/Underinsured Motorist (SUM) coverage from State Farm after being injured in a police vehicle accident driven by Officer Knauss. Fitzgerald claimed coverage under Knauss's SUM endorsement, while State Farm argued that police vehicles did not fall under the statutory definition of "motor vehicle" in the Insurance Law § 3420 (f) (2) (A). The court examined legislative history and amendments, emphasizing that historically, police vehicles were excluded from civil liability statutes and that SUM coverage extended only to injuries arising from non-police vehicles. The holding reaffirmed the interpretation that SUM coverage did not apply to injuries sustained in police vehicle accidents, in line with the historical exclusion and legislative intent.