No-Fault Case Law

The court considered the issue of a provider seeking to recover assigned first-party no-fault benefits and whether there was a lack of medical necessity for the supplies at issue. Plaintiff moved for summary judgment, and defendant cross-moved for summary judgment dismissing the complaint. The Civil Court denied plaintiff's motion, made findings in plaintiff's favor, and held that the only remaining issue for trial was medical necessity. Defendant submitted an affirmed peer review report showing a lack of medical necessity for the supplies, which was unrebutted by plaintiff. The Appellate Term reversed the lower court's decision, vacated the findings in plaintiff's favor, and granted defendant's motion for summary judgment dismissing the complaint, based on the lack of medical necessity for the supplies at issue.

The court considered the motion for summary judgment by the defendant to dismiss the complaint brought by the plaintiff, Longevity Medical Supply, Inc. In this case, the defendant alleged that the claims had been properly denied due to the plaintiff's failure to appear at scheduled examinations under oath (EUOs). The main issue decided by the court was whether the defendant had established that its procedure for mailing denial of claim forms had been followed and if the requests for EUOs were timely. The court held that the defendant had provided sufficient evidence to establish that the mailing procedures for EUO scheduling letters and denial of claim forms had been followed, and that the requests for EUOs were timely. As a result, the court reversed the lower court's denial of the defendant's motion for summary judgment and granted the motion to dismiss the complaint.

The main issue in this case was whether the defendant had issued an insurance policy covering the accident in question. Plaintiff, a provider seeking to recover assigned first-party no-fault benefits, moved for summary judgment, while the defendant cross-moved for summary judgment dismissing the complaint. The court considered the affidavit from the defendant's no-fault examiner, which sufficiently established the defendant's lack of coverage defense. Despite the plaintiff's argument that the defendant was required to describe the steps taken to search its records, the court held that the defendant had demonstrated that it was not the carrier which covered the accident in question. Therefore, the court 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 Optimal Well-being Chiropractic, P.C. was seeking to recover assigned first-party no-fault benefits from Utica Mutual Insurance Company. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint. The holding of the case was that the defendant's appeal was denied, as they failed to establish that the defenses of the plaintiff's assignor failing to appear for independent medical examinations and the plaintiff seeking to recover for treatment not received were not precluded. The court also found that the defendant was not entitled to summary judgment on the ground of lack of medical necessity. Therefore, the order, insofar as appealed from, was affirmed.

The main issue in this case was whether the defendant had timely and properly denied the claim at issue based on the plaintiff's assignor's failure to appear for independent medical examinations (IMEs). The court considered the affidavits provided by both the defendant and the plaintiff, as well as the standard mailing practices and procedures of the IME scheduling letters. Ultimately, the court held that the defendant's motion for summary judgment dismissing the complaint should have been granted, as the plaintiff had not provided sufficient evidence to rebut the presumption of receipt of the IME scheduling letters. The appearance of an assignor at a duly scheduled IME was determined to be a condition precedent to the insurer's liability on the policy. Therefore, the court reversed the lower court's decision and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the affidavits and evidence submitted by both the plaintiff and the defendant, in relation to a motion for summary judgment. The main issue decided was whether the defendant timely denied the plaintiff's claims for first-party no-fault benefits, and whether the fees charged by the plaintiff for acupuncture services exceeded the amount permitted by the applicable worker's compensation fee schedule. The court held that the defendant's motion for summary judgment dismissing the complaint was granted in its entirety, as the defendant established prima facie that it timely denied the claims and that the fees charged exceeded the permitted amount. The court found that the plaintiff failed to raise a triable issue regarding the efficacy of the denial or the calculation of the fee, and therefore the motion for summary judgment should have been granted in favor of the defendant.

The relevant facts presented to the court were that an automobile accident occurred in April 2011 and the owner and driver of the vehicle, Gregory Huff, assigned his no-fault insurance benefits to medical providers. The insurance company, American States Insurance Company, brought the action to argue that it was not obligated to pay the no-fault benefits to the medical providers due to Huff's failure to complete an Examination Under Oath (EUO) as required by the insurance policy. The company argued that this failure breached a condition precedent to coverage under the policy and therefore the medical providers were not entitled to recover Huff's no-fault benefits. The main issue decided by the court was whether the insurance company was justified in disclaiming coverage based on the insured’s failure to complete an EUO. The court held that the Supreme Court properly granted summary judgment in favor of the insurance company, declaring that the disclaimer of coverage was proper. The court affirmed the decision, finding that the EUO transcript was admissible evidence and that the defense of the breach of a condition precedent to coverage under the policy was valid against the medical providers who accepted assignments of no-fault benefits.

The court considered the defendant-insurer's argument that it was entitled to summary judgment dismissing the action for first-party no-fault benefits because it had properly and timely mailed notices for independent medical examinations (IMEs) to the plaintiff's assignor and his counsel, and the assignor failed to appear. The insurer presented affidavits from the scheduled examining physician and an employee of the insurer's third-party biller attesting to the assignor's nonappearance. The plaintiff did not specifically deny the assignor's nonappearance or raise a triable issue with respect to the mailing or reasonableness of the notices. The main issue decided was whether the insurer was entitled to summary judgment dismissing the complaint. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted in its entirety because the insurer made a prima facie showing of entitlement to summary judgment.

The relevant facts of Westchester Medical Center v Mapfre Insurance Company of New York involved an action to recover no-fault medical payments under an insurance contract. The plaintiff, Westchester Medical Center, sought to recover these payments from the defendant, Mapfre Insurance Company of New York, after they were not paid within 30 days of the defendant's receipt of the prescribed claim forms. The plaintiff moved for summary judgment on the complaint, but the defendant raised a triable issue of fact as to whether it timely and properly denied the claim based on the alleged intoxication of the plaintiff's assignor at the time of the accident by issuing a denial within 30 days of the receipt of additional verification it requested concerning the claim. Ultimately, the Supreme Court denied the plaintiff's motion for summary judgment on the complaint, and the order was affirmed by the Appellate Division. The main issue decided was whether the defendant sufficiently raised a triable issue of fact as to the timely and proper denial of the claim, and the holding was that they did, leading to the denial of the plaintiff's motion for summary judgment.

The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits, and the defendant moved for summary judgment dismissing the complaint based on the failure of the plaintiff's assignor to appear for scheduled examinations under oath (EUOs). The District Court denied the defendant's motion, and the defendant appealed. The main issues that were decided included whether the insurer's notice of scheduling an EUO needed to specify the reason(s) why the EUOs were being required, and whether the time to pay or deny a claim had been tolled by the timely issuance of EUO scheduling letters. The holding of the case was that the branches of the defendant's motion seeking summary judgment dismissing the first, fourth, and fifth causes of action of the complaint were granted in part and denied in part, and the order was modified accordingly.