No-Fault Case Law

The relevant facts of this case involved a plaintiff who sought to recover no-fault benefits under an automobile insurance policy after she tripped and injured her knee while exiting a car. The main issue the court decided was whether the plaintiff's injury arose from the use or operation of a motor vehicle, which is required for entitlement to first-party benefits under section 5103 of the Insurance Law. The court held that the plaintiff did not establish her prima facie entitlement to judgment on the complaint, because she testified and submitted an affidavit indicating that her accident was unrelated to the use or operation of the vehicle. The defendant, on the other hand, established prima facie that the injury did not arise from the use or operation of a vehicle, as supported by the plaintiff's application for no-fault benefits and signed statement regarding the circumstances of the accident. Therefore, the court affirmed the order, denying the plaintiff's motion and granting the defendant's cross motion for summary judgment dismissing the complaint.

The court considered the fact that defendant had received a claim form listing five different medical supplies for which the plaintiff sought reimbursement as assignee of the injured party. Defendant had timely mailed its verification request and follow-up verification request and had not received the requested verification. Plaintiff did not show that such verification had been provided to the defendant prior to the commencement of the action on the claim. Consequently, the 30-day period within which defendant was required to pay or deny the claim did not begin to run. The main issue decided was whether the defendant was required to pay or deny the claim within the 30-day period. The holding was that the defendant's motion seeking summary judgment dismissing the complaint as to the KO custom rigid knee support was granted because plaintiff's action was deemed premature.

The court considered the appeal from a judgment of the Civil Court of the City of New York, Kings County, which had dismissed the complaint by a provider to recover assigned first-party no-fault benefits. The main issue was whether the denial of the plaintiff's claims was valid, as they exceeded the amount permitted by the workers' compensation fee schedule and the defendant had fully paid for the billed-for services in accordance with the fee schedule for acupuncture services performed by chiropractors. The court held that the defendant's affidavit sufficiently established the timely mailing of the denial of claim forms, and the plaintiff's papers failed to raise a triable issue of fact in opposition to the defendant's motion. As a result, the judgment of the Civil Court was affirmed.

In this case, the defendant-insurer appealed an order from the Civil Court of the City of New York which denied, in part, its motion for summary judgment dismissing the complaint. The insurer made a prima facie showing of entitlement to summary judgment dismissing the plaintiff's no-fault claims for medical supplies provided to the assignor, establishing proper and timely mailing of denial of claim forms and submitting a sworn peer review report stating that the medical supplies were not medically necessary. The plaintiff's opposing submission was deemed insufficient to raise a triable issue, as it consisted of an attorney's affirmation unaccompanied by any medical evidence or other competent proof. The Court affirmed the order in part, granting the defendant's motion for summary judgment dismissing claims in the aggregate amount of $1,710.05, but also sustained the denial of the defendant's motion for summary judgment dismissing the $1,080 claim for medical supplies provided to the assignor on June 27, 2011.

The court considered the defendant-insurer's motion for summary judgment dismissing the complaint from the plaintiff, who was appealing the denial of a claim for no-fault first-party benefits. The defendant-insurer made a prima facie showing of entitlement to judgment by demonstrating that it timely and properly denied the claim through the affidavits of employees detailing their mailing procedures and the peer review report of its orthopedic doctor, which stated that the medical supplies provided were not medically necessary. The court found that the plaintiff's opposition, consisting of an attorney's affirmation unaccompanied by any medical evidence or other competent proof, was insufficient to raise a triable issue as to medical necessity. Therefore, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, with costs.

The court considered the defendant-insurer's motion for summary judgment dismissing the complaint made by the plaintiff-provider, SMB Medical, P.C., which claimed for first-party no-fault benefits in the amount of $662.89. The defendant established that it timely and properly mailed the notices for independent medical examinations to the plaintiff's assignor and his counsel, and that the assignor failed to appear. The plaintiff argued that the defendant did not submit competent evidence of the assignor's nonappearance, but the court found that the defendant did, in fact, submit competent evidence of the nonappearance. As a result, the court held that the defendant's motion for summary judgment dismissing the complaint is granted in its entirety. The decision was made on December 30, 2014, and the order was reversed, with the defendant being directed to enter judgment accordingly.

The court was presented with a case in which an order had been previously made which granted plaintiff's motion for summary judgment, declaring that defendants-appellants were not entitled to no-fault benefits. Plaintiff had established that defendants were not entitled to these benefits because assignors failed to appear at scheduled examinations under oath (EUOs). This court had previously held that the failure to submit to requested independent medical examinations (IMEs) constitutes a breach that voids coverage. The defendants had failed to appear at their first and second EUOs. The court declared that defendants were not entitled to no-fault benefits because of this. The plaintiff's appeal was unanimously modified on the law to declare that the defendants were not entitled to no-fault benefits, and the original decision was otherwise affirmed.

The court considered the motions for summary judgment in an action by a medical provider to recover no-fault benefits. The main issue was whether the plaintiff was entitled to summary judgment and whether the defendant had met the burden of demonstrating timely and valid cancellation of the insurance policy. The court held that the plaintiff was not entitled to summary judgment as it failed to demonstrate that the defendant had failed to timely deny the claims or that the denial of claim forms were conclusory, vague, or without merit as a matter of law. The burden then shifted to the defendant to demonstrate the timely and valid cancellation of the insurance policy based on nonpayment of the premium, which the defendant was able to do. Since the plaintiff did not submit any opposition to the defendant's cross motion, no triable issue of fact was raised as to the validity of the cancellation of the policy, and the order was affirmed.

The court considered a dispute between Health Needles Acupuncture, P.C. and GEICO Ins. Co. regarding the reimbursement for acupuncture services rendered by Health Needles. The main issue was whether GEICO properly used the workers' compensation fee schedule applicable to chiropractors to reimburse Health Needles for the services rendered. The court held that GEICO had demonstrated that it had fully paid Health Needles for the services at issue in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors, and affirmed the lower court's decision to grant summary judgment to GEICO and deny Health Needles' motion for summary judgment on most of the claims.

The court considered whether the plaintiff, XVV, Inc., as assignee of RAFAEL VERAS, was entitled to recover assigned first-party no-fault benefits from Praetorian Ins. Co. The main issue was whether the defendant had timely and properly denied the claims based on the plaintiff's assignor's failure to appear for examinations under oath (EUOs) and independent medical examinations (IMEs). The court held that the defendant's cross motion for summary judgment dismissing the first cause of action should have been granted, as the defendant had established that IME and EUO scheduling letters had been timely mailed and the plaintiff's assignor failed to appear for the duly scheduled IMEs and EUOs. However, the court also held that the branch of defendant's cross motion seeking summary judgment dismissing plaintiff's second cause of action was properly denied, as the defendant failed to establish, as a matter of law, that it had timely denied this claim. Therefore, the court modified the order by granting summary judgment dismissing plaintiff's first cause of action and affirmed the order as modified.