No-Fault Case Law

The relevant facts in the case include an insured driver being in an accident and another driver's insurance company refusing to pay. The main issue before the court was whether the insurer was obligated to pay despite their claim of noncooperation from the driver. The appellate division upheld the original judgment against the insurance company. The court held that the arbitration awards would be upheld if there was evidence to support them, which there was in this case. This was based on the interpretation of the Insurance Law and the insurer's direct right to recover loss transfer reimbursement from the adverse insurer, even if the adverse insurer had disclaimed coverage.

The court considered the issue of whether an insurance company is required to schedule an examination before trial (EUO) of a medical provider within 15 business days after completing the assignment's EUO. The case raised tensions between treating the EUO as a condition precedent to coverage and as part of the verification procedures. The insurance company failed to issue a scheduling letter to the provider for an EUO within the required 15 business days, but later issued a denial based on the provider's failure to appear for the EUO. The court ultimately held that the insurance company forfeited its right to issue an untimely denial as permitted by a prior decision and the time in which to issue the denial was reduced by the insurance company's untimely request for an additional EUO. The insurance company's motion for summary judgment was granted, and the plaintiff's cross motion for summary judgment was denied.

The court considered the defendant's motion for summary judgment in a case where the plaintiff, Rutland Medical, P.C., was the assignee of Ted Nimmons, and the defendant was State Farm Insurance Company. The main issue decided was whether the defendant established the timely and proper generation and mailing of examination under oath (EUO) scheduling letters, and whether the plaintiff's failure to appear on the scheduled EUO dates was valid. The court held that the defendant had proven the timely mailing of the EUO requests and plaintiff's failure to appear, but the plaintiff raised a question of fact with respect to the reasonableness of the EUO requests and the defendant's failure to respond. Therefore, the court decided that the matter shall proceed to trial on the issues of plaintiff's prima facie case and the reasonableness of defendant's EUO requests.

The court considered a case involving the New York City Transit Authority and GEICO General Insurance Company. The main issue was whether the arbitrator's award to GEICO was improper and exceeded its power, as the arbitrator refused to consider a jury verdict finding GEICO's insured 100% responsible for an accident. The court held that the arbitrator's decision to not consider the final judgment of the jury was irrational and exceeded its power. The court also stated that the claim brought by GEICO in the arbitration had already been fully litigated and determined by a court, and therefore should have been given preclusive effect. As a result, the court granted the petition to vacate the arbitrator's determination and remanded the matter back to arbitration to be heard by the same arbitrator, while denying GEICO's cross motion.

The appellate court considered a case where an insurance company appealed the denial of their motion for summary judgment on a no-fault claim for acupuncture services. The main issue was whether the peer review report provided by the defendant-insurer was sufficient to establish that the acupuncture services lacked medical necessity. The holding was that the peer review report was insufficient to establish, as a matter of law, that the acupuncture services lacked medical necessity, as the report was based on narrow grounds and did not conclusively show that the medical condition could never warrant further acupuncture treatments. Therefore, the summary judgment dismissal of the claim was properly withheld. The court also noted that the dismissal of the plaintiff's remaining claim was not properly before them due to the absence of a cross appeal by the plaintiff.

The plaintiff appealed from an order of the Supreme Court in an action to recover no-fault medical benefits under an insurance contract, which granted the defendant's motion to vacate a clerk's judgment entered in favor of the plaintiff and against the defendant. The defendant sought to vacate a default in answering or appearing by demonstrating a reasonable excuse for the default and a potentially meritorious defense to the action. The defendant established a reasonable excuse through an employee's affidavit and attested to a clerical oversight regarding the delay in forwarding the summons with notice to its attorney. The defendant also demonstrated a potentially meritorious defense to the action. The Supreme Court exercised its discretion in granting the defendant's motion to vacate the default judgment, to extend its time to appear, and to compel the plaintiff to accept its late notice of appearance. Therefore, the order was affirmed.

The court considered the case of Epic Pain Management & Anesthesia Consultants, LLC appealing an order granting New York Central Mutual Fire Ins. Co.'s motion for summary judgment to dismiss the complaint. The main issue decided was whether the action seeking recovery of assigned first-party no-fault benefits arising from a series of epidural injections administered in Hackensack, New Jersey, was ripe for summary dismissal. The court held that the action was not ripe for summary dismissal as the defendant failed to address or refute the applicability of Insurance Department regulation (11 NYCRR) § 68.6, which provides that the permissible charge for a reimbursable health service performed outside New York State shall be the prevailing fee in the geographic location of the provider. The court reversed the order, denied the motion, and reinstated the complaint, finding that genuine triable issues were created by the defendant's arguments.

The case involved an action to recover first-party no-fault benefits. The issue before the court was whether the no-fault carrier could request a medical provider submit to an examination under oath (EUO) after previously denying all further no-fault benefits based on an independent medical examination (IME). Cecilio Pablo-Rodriguez, the eligible injured party, had his treatment for a motor vehicle accident injury denied by Allstate Insurance Company on the grounds of failing to appear for an EUO. However, Rodriguez's attorney had timely objected to Rodriguez being produced for an EUO. The court held that Allstate had not provided an objective basis for requesting Rodriguez appear for an EUO after the objection, therefore denying Allstate's motion for summary judgment. The main issues decided were whether Allstate had an objective basis for requesting an EUO after Rodriguez's attorney's timely objection, and whether the carrier could request an EUO after denying no-fault benefits based upon an IME. The court held that when the party who is requested to appear for an EUO timely objects to appearing for the EUO, the carrier must establish it had an objective standard for requesting the EUO, and that a carrier, even after denying no-fault benefits based on an IME, can request an EUO of the eligible injured party if the party continues to receive medical treatment and the provider continues to submit the no-fault claims for payment.

The court considered the defendant-insurer's motion to dismiss the complaint unless the plaintiff complied with the notice of deposition. The main issue decided was whether the defendant was entitled to depositions relating to its excessive treatment and fee schedule defenses, in light of the fact that it did not demonstrate entitlement to those depositions by timely denying the plaintiff's first-party no-fault claim. The court ultimately held that the defendant-insurer failed to demonstrate entitlement to the depositions and reversed the order, denying the defendant's motion. As a result, the defendant's motion to dismiss the complaint was also denied by the court.

The main issue decided in this case was whether the action was barred under the doctrine of res judicata and whether the plaintiff failed to establish its prima facie entitlement to summary judgement. The court considered the fact that the defendant had timely mailed EUO scheduling letters to the assignor and that the assignor had failed to appear for scheduled EUOs. The court also considered the Supreme Court's declaratory judgment, which found in favor of the defendant, American Transit. The holding of the case was that the action was indeed barred under the doctrine of res judicata, and the court affirmed the order of the Civil Court, which had granted the defendant summary judgment dismissing the complaint with prejudice.