No-Fault Case Law

The main issue in this case was whether the defendant, New York Central Mutual Fire Insurance Company, had timely denied the two claims at issue on the ground of lack of medical necessity. The defendant argued that they had timely mailed their denial of claim forms, which denied the claims. However, conflicting medical expert opinions were presented by the parties, demonstrating the existence of a triable issue of fact as to whether there was a lack of medical necessity for the services provided. The court ultimately held that the order denying the defendant's motion for summary judgment dismissing the complaint was affirmed, as the conflicting expert opinions were sufficient to demonstrate the existence of a triable issue of fact.

The court considered the facts of a motor vehicle accident involving passengers in a U-Haul truck, for which the U-Haul was insured by Repwest Insurance Company. The passengers allegedly refused medical attention at the scene of the accident and later sought treatment for injuries sustained from the collision. Repwest Insurance Company (Repwest Ins.) sent requests for examinations under oath (EUOs) to the Defendant Claimants, but they failed to appear. As a result, Repwest Ins. denied all no-fault coverage for the claims submitted by the medical provider defendants based on the failure to attend the scheduled EUOs. The main issue decided by the court was whether the Defendant Claimants were entitled to no-fault coverage, and the holding of the case was that the Answering Defendants, Comprehensive Psychological Evaluation, P.C. and Orthoplus Products, Inc., were not entitled to no-fault coverage as they failed to attend the EUOs. The court granted Repwest Ins.'s motion for summary judgment against the Answering Defendants.

The relevant facts considered by the court were that the plaintiff, Flushing Traditional Acupuncture, provided acupuncture services to an injured individual who was covered by a no-fault insurance policy with Kemper Insurance Company. Subsequently, Kemper filed a declaratory judgment action against the plaintiff and other providers, alleging breach of the insurance policy for failing to appear for scheduled examinations under oath. The Supreme Court entered a judgment declaring that the plaintiff and other providers were not entitled to recover no-fault benefits. The main issue decided was whether the present action by the plaintiff to recover assigned first-party no-fault benefits was barred under the doctrine of res judicata due to the prior judgment entered by the Supreme Court. The holding of the court was that the present action was indeed barred by the doctrine of res judicata, as any judgment in favor of the plaintiff would destroy or impair rights or interests established by the Supreme Court judgment. Therefore, the court affirmed the order granting Kemper's motion to dismiss the complaint.

The court considered an action for a declaration that the plaintiff has no obligation to pay certain no-fault claims. The key legal issue was whether the defendants were entitled to recover no-fault benefits, as the failure to comply with the provision of an insurance policy requiring the insured to submit to an examination under oath is a material breach of the policy, precluding recovery of the policy proceeds. The court held that the plaintiff insurer established as a matter of law that it twice duly demanded an examination under oath from the appellants' assignor, who failed to appear, and that the plaintiff issued a timely denial of the claims arising from the appellants' treatment of the assignor. The appellants failed to raise a triable issue of fact as to the propriety of the demand for the examination under oath or whether the assignor actually appeared at the examination, and also failed to demonstrate that discovery might lead to relevant evidence or that the facts essential to justify opposition to the motion were exclusively within the knowledge and control of the movant. Therefore, the judgment was affirmed in favor of the plaintiff insurer.

The main issue in the case was whether the plaintiff Westchester Medical Center, as the assignee of Paul Knable, was entitled to summary judgment in an action to recover no-fault insurance benefits from the defendant insurance company, Allstate Insurance Company. The primary argument of the defendant was that the hospital did not make a prima facie showing of entitlement to judgment as a matter of law on the first cause of action. The court found that the hospital did make a prima facie showing of entitlement to judgment as a matter of law and that the defendant failed to raise a triable issue of fact. The court also determined that the defendant was under a regulatory duty to issue a second request for verification within 10 days after the expiration of a 30-day period, and since there was no such second request, the defendant's contention that the 30-day period had been extended had no merit. As a result, the court held that the hospital's motion for summary judgment on the first cause of action should have been granted.

The relevant facts in the case of Drew De Marco, P.C. v Allstate Ins. Co. include the plaintiff suing to recover first-party no-fault benefits for chiropractic services rendered to the insured assignor in the form of manipulation under anesthesia (MUA). The main issue decided was whether the trial court properly precluded the defendant's chiropractor, Dr. Kevin Portnoy, from testifying as an expert on MUA procedures, which led to the court directing a verdict in favor of the plaintiff. The holding of the case was that the trial court's decision was reversed and a new trial was ordered. The court found that the defendant's chiropractor, Dr. Kevin Portnoy, was qualified as a chiropractic expert based on the parties' open court stipulation, and therefore did not need to be certified as an MUA specialist to offer an opinion on the medical necessity of the MUA procedures in question. Therefore, his lack of certification in this area only affected the weight to be accorded to his testimony, not its admissibility.

Main issues decided: The sole issue submitted for trial was the validity of the late notice defense. Holding: The court rejected the defendant's late notice defense. The court found that in the absence of explicit notice to the applicants that their late claims could be excused upon submission of a reasonable explanation for the delay, the defendant could not maintain that a "condition precedent" for no-fault coverage was breached. Therefore, plaintiff was awarded judgment on its claims for no-fault benefits, as requested in its complaint.

The court considered whether the defendant, State Farm Mutual Insurance Company, was entitled to summary judgment dismissing the complaint brought by Concourse Chiropractic, PLLC as the assignee of ODALIS GUZMAN to recover assigned first-party no-fault benefits. The main issues decided were whether the examination under oath (EUO) notices had been timely sent to the plaintiff, whether the plaintiff had failed to appear for the EUOs, and whether the defendant had demonstrated that the claims underlying these causes of action had been timely denied based on plaintiff's nonappearance at the EUOs. The holding of the case was that with respect to the first through sixth and ninth and tenth causes of action of the complaint, the defendant's motion for summary judgment was granted, as it had been established that the EUO notices had been timely sent to the plaintiff and that the plaintiff had failed to appear for the EUOs. However, with respect to the seventh and eighth causes of action, where it was undisputed that the defendant paid the claim underlying those causes of action but had failed to establish that its payment was timely, the motion for summary judgment was properly denied.

The court considered the requirements for submitting a claim for health service expenses under no-fault insurance benefits in New York. The main issue was whether the plaintiff had established a prima facie case for entitlement to the claimed amount of benefits. The court decided that the plaintiff failed to provide competent proof of the economic loss claimed, as the submitted evidence was not admissible to establish the facts asserted in the claim forms. Therefore, the court held that the plaintiff's motion for summary judgment on the complaint was denied, except as to a specific claim in a reduced amount, and remitted the matter to the lower court for further calculation and determination of the amount owed to the plaintiff for no-fault benefits.

The court considered conflicting medical expert opinions regarding the medical necessity of the diagnostic tests underlying the plaintiff's first-party no-fault claim. The main issue decided was whether the conflicting medical expert opinions raised a triable issue as to the medical necessity of the diagnostic tests. The court held that the conflicting medical expert opinions sufficed to raise a triable issue as to the medical necessity of the diagnostic tests underlying the plaintiff's first-party no-fault claim. Therefore, the court affirmed the order of the Civil Court of the City of New York, Bronx County, which denied the defendant's motion for summary judgment dismissing the complaint.