No-Fault Case Law

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.

The court considered the fact that the plaintiff, Delta Diagnostic Radiology, P.C., was seeking to recover no-fault benefits as an assignee of Jean Brouard. The main issue decided was whether there was fraudulent procurement of the insurance policy in question, as the defendant, National Liability & Fire Insurance Co., alleged that Brouard had misrepresented his place of residence. The court held that there was a triable issue of fact as to whether Brouard had provided a fraudulent address when obtaining the insurance policy, and thus, plaintiff's motion for summary judgment was denied. Additionally, the court found that the defendant failed to make a prima facie showing of entitlement to judgment dismissing the complaint as a matter of law. Therefore, the order was modified to provide that plaintiff's motion for summary judgment was denied.

The court considered the fact that Ultimate Health Products, Inc. had initiated a lawsuit to recover assigned first-party no-fault benefits for supplies provided to an individual who was injured in a motor vehicle accident. American Transit Insurance Company had also initiated a separate lawsuit, alleging that the injured individual had breached the insurance policy terms. In the end, the Supreme Court determined that the injured individual was not eligible for no-fault benefits and American Transit was not obligated to pay any claims for first-party no-fault benefits. The main issue was whether the present action was barred under the doctrine of res judicata, and the court held that it was, as any judgment in favor of the plaintiff in this action would destroy or impair rights or interests established by the Supreme Court declaratory judgment. Therefore, the court affirmed the order to dismiss the complaint.

The court considered whether the defendant's law firm should be disqualified in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant submitted sufficient proof to show that the plaintiff had failed to appear for scheduled examinations under oath, and whether the law firm representing defendant should be disqualified based on the attorney/witness rule. The holding of the case was that the defendant had submitted sufficient proof to show that the plaintiff had failed to appear for scheduled examinations under oath, and that the law firm representing the defendant did not need to be disqualified. Therefore, the judgment was affirmed.

The relevant facts considered by the court were that the plaintiff, Natural Therapy Acupuncture, P.C., was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co., and the defendant had denied the claims at issue on the ground that the plaintiff had failed to comply with a condition precedent to coverage, in that they had failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided by the court was whether the defendant's EUO requests were justified and whether the plaintiff had failed to comply with the requests. The holding of the case was that the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, as the defendant had established that the EUO scheduling letters and the denial of claim forms had been timely mailed and the plaintiff had failed to appear for the EUOs, and the plaintiff's objections regarding the EUO requests were not considered as they had not responded in any way. Therefore, discovery relevant to the reasonableness of the EUO requests was not necessary for the plaintiff to oppose the defendant's motion.

The relevant facts of the case were that an insurance company had timely mailed verification requests to a medical care provider, but had not received the requested verification. The main issue decided by the court was whether the insurance company had to prove that the copies of the verification letters had not been tampered with or altered. The court held that there was nothing in the record requiring the insurance company to prove that the copies had not been tampered with, and that as a result, the medical care provider's action was premature. Therefore, the court reversed the findings in favor of the medical care provider and granted the insurance company's cross motion for summary judgment dismissing the complaint.

The main issue in Matter of Unitrin Direct/Warner Insurance Company v Joseph Brand was whether arbitration should be permanently stayed regarding a claim for supplementary uninsured/underinsured motorist benefits. The appellate division affirmed the order granting the petition, holding that this dispute was a contractual matter to be governed by the conflict of law rules relevant to contracts, not torts. The court found that New York had more significant contacts with the parties and the contract, and that SUM coverage was not triggered under New York law because the offending vehicle was not underinsured. Brand's reliance on Florida law was found to be inapplicable in this case, as the relevant insurance contract was written to conform to the laws, rules, and regulations of New York State, and was obtained in New York by Brand, a New York resident. The court also rejected Brand's contention that Unitrin's payment of first-party benefits constituted an agreement that Florida law controls.

The court considered the plaintiff's claim for reimbursement of $844.13 for medical services rendered to Mr. Jacques Gladys. State Farm Mutual Automobile Insurance Co. denied the claim on the basis that the medical provider failed to appear for two scheduled examinations under oath. State Farm Mutual Automobile Insurance Co. moved for summary judgement on the ground that the medical provider failed to appear for two scheduled examinations under oath and is therefore in breach of a condition precedent to coverage. Michael Sirignano's affirmation was determined to be sufficient to prove the provider's nonappearance for the examinations. The affidavit provided by Sirignano and his personal knowledge of those failed appointments are sufficient and outweighed by the plaintiff's other arguments, resulting in that State Farm Mutual Automobile Insurance Co. be entitled to summary judgment.