No-Fault Case Law

The court considered the conflicting medical expert opinions adduced by the parties as to the medical necessity of the acupuncture services sued for. Plaintiff had also acknowledged that issues of fact existed, warranting a trial on the issue of medical necessity. The main issue decided was whether the motion court properly searched the record and awarded summary judgment to plaintiff on its claim for first-party no-fault benefits. The court held that the motion court improperly granted summary judgment to the plaintiff, as there were conflicting medical expert opinions and acknowledged issues of fact warranting a trial. The court also found no abuse of discretion in the denial of defendant's motion to compel the deposition of plaintiff's treating provider on this record, as defendant failed to set forth an "articulable need" for the provider's deposition.

The relevant facts that the court considered were that the defendant had been retained to schedule independent medical examinations (IMEs) and had timely mailed scheduling letters for these examinations, but the plaintiff's assignor had failed to appear for the scheduled IMEs. The defendant also provided affidavits to establish the timely mailing of denial of claim forms. The main issue decided in the case was whether the plaintiff had met the conditions precedent for the insurer's liability on the policy, specifically regarding the assignor's appearance at the IMEs. The holding of the court was that the judgment was reversed, the order granting the plaintiff's motion for summary judgment was vacated, and the defendant's cross motion for summary judgment dismissing the complaint was granted. Therefore, the plaintiff's motion for summary judgment was denied.

The court considered that the defendant had timely mailed letters scheduling examinations under oath (EUOs) and the denial of claim form, and submitted certified transcripts of the scheduled EUOs, which demonstrated that the plaintiff's assignor had failed to appear. The plaintiff did not claim to have responded in any way to the EUO requests. Therefore, the defendant had demonstrated that the plaintiff had failed to satisfy a condition precedent to the defendant's liability on the insurance policy. The main issue decided was whether the defendant had provided sufficient evidence to show that the plaintiff had failed to satisfy a condition precedent to the defendant's liability on the insurance policy. The holding of the case was that the order denying the defendant's cross motion for summary judgment dismissing the complaint was reversed, and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The main issues in this case were whether the defendant had timely denied the claims at issue based upon the plaintiff's assignor's failure to appear for scheduled independent medical examinations (IMEs) and whether the IME scheduling letters had been timely mailed in accordance with the office's standard mailing practices and procedures. The court noted that the only issue for trial was "the mailing of the IME scheduling letters." In support of its motion, the defendant submitted an affidavit by an employee of the company which had been retained by defendant to schedule IMEs, establishing that the IME scheduling letters had been timely mailed. The court found that as the plaintiff had not challenged the Civil Court's finding, in effect, that defendant is otherwise entitled to judgment, the order was reversed and defendant's motion for summary judgment dismissing the complaint was granted.

The main issue in this case was whether the defendant had timely mailed and properly scheduled independent medical examinations (IMEs) for the plaintiff. The court considered whether the initial scheduling letters had been timely mailed to the plaintiff, as required by Insurance Department Regulations. Defendant alleged that it had timely denied the claims at issue based upon plaintiff's assignor's failure to appear for duly scheduled IMEs. In support of its motion, defendant submitted an affidavit by an employee of the company which had been retained by defendant to schedule IMEs, which established that the IME scheduling letters had been timely mailed to plaintiff's assignor. The court decided that it was not necessary to mail the initial scheduling letters to plaintiff, and reversed the Civil Court's order, granting the defendant's motion for summary judgment dismissing the complaint.

The main issue in this case was whether the insurance company, NY Central Mutual Fire Ins. Co., had timely denied claims for first-party no-fault benefits based on the plaintiff's assignor's failure to appear for independent medical examinations (IMEs). The court considered affidavits from the company employee who scheduled the IMEs and the healthcare professionals who were to perform the IMEs, as well as an affidavit from the defendant's litigation examiner describing the standard mailing practices and procedures for verification requests and denial of claim forms. The court held that the assignor's appearance at the IMEs was a condition precedent to the insurer's liability on the policy, and as a result, the defendant's motion for summary judgment dismissing the complaint was granted.

The relevant facts the court considered in this case were that SK Prime Medical Supply, Inc. sought to recover $201.96 in first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The issue before the court was whether State Farm's denial of $200 of the claim at issue due to a deductible was appropriate, and whether the remaining amount sought by SK Prime was accurate based on the Durable Medical Goods Fee Schedule for Workers' Compensation. The holding of the court was that State Farm demonstrated the timely mailing of the denial of claim form and that the denial of $200 of the claim due to the deductible was proper. Additionally, State Farm's submission of its claims representative's affidavit and a copy of the fee schedule was sufficient to demonstrate that SK Prime was only entitled to receive $22.04 for a specific medical code, not the $24.00 billed by SK Prime. Therefore, the order granting State Farm's motion for summary judgment dismissing the complaint was affirmed.

The court considered the denial of medical claims by the defendant on the grounds of lack of medical necessity and failure to comply with verification requests. The main issues decided were whether the provider had established medical necessity for the denied claims and whether they had complied with the defendant's verification requests. The holding of the case was that the defendant's cross motion for summary judgment dismissing the complaint was granted, except for claims totaling $114.33 and $82.89, which were not addressed adequately by the defendant. Therefore, the order was modified to reflect this decision.

The court considered the fact that Right Aid Medical Supply Corp. as Assignee of Doleres Wong moved for summary judgment to recover assigned first-party no-fault benefits, but the Civil Court denied the motion and limited the issues for trial to the timeliness and propriety of the defendant's denial of claim forms and to the defenses preserved in such denials. The main issue decided was whether the Civil Court, in effect, granted plaintiff's motion for summary judgment, and whether it should have made CPLR 3212 (g) findings in plaintiff's favor. The holding of the case was that the court did not grant plaintiff's motion for summary judgment, but rather limited the issues of fact for trial, which it is permitted to do when a motion for summary judgment is denied or partially denied. The order, insofar as appealed from, was affirmed.

The relevant facts the court considered in this case were that the plaintiff, a medical provider, moved for summary judgment to recover assigned first-party no-fault benefits from the defendant insurance company. The Civil Court denied the motion but limited the issues for trial to the timeliness and propriety of the defendant's denial of claim forms and to the defenses preserved in such denials. On appeal, the defendant argued that the Civil Court effectively granted the plaintiff's motion for summary judgment and should not have made findings in the plaintiff's favor under CPLR 3212(g). The main issue decided was whether the Civil Court erred in limiting the issues for trial and making findings in the plaintiff's favor, and the holding was that the order, insofar as appealed from, was affirmed because the court did not grant the plaintiff's motion for summary judgment and was permitted to limit the issues of fact for trial under CPLR 3212(g).