No-Fault Case Law

The court considered an action by a provider to recover assigned first-party no-fault benefits, where the plaintiff moved for summary judgment and the defendant cross-moved for summary judgment dismissing the complaint based on a lack of medical necessity. The Civil Court made findings in the plaintiff's favor and held that the only remaining issue for trial was medical necessity. The main issue decided was whether there was a triable issue of fact regarding the medical necessity of the services at issue. The holding was that there was a triable issue of fact regarding the medical necessity of the services, and the order was affirmed. The defendant failed to articulate a sufficient basis to strike the Civil Court's findings in the plaintiff's favor, and the court found that there is a triable issue of fact regarding the medical necessity of the services at issue.

The relevant facts considered by the court were that Imperium Insurance Company sued Innovative Chiropractic Services and Park Slope Advanced Medical seeking declaratory relief and review of five master arbitrator's awards issued in favor of the defendants on their claims for first-party no-fault benefits. The main issue decided was whether the court had jurisdiction to entertain the lawsuit and whether the dismissal of the consolidated actions was warranted on the merits. The holding of the court was that while the Civil Court had jurisdiction to entertain the lawsuit, the dismissal of the consolidated actions on the merits was sustained because de novo review of the master arbitrator's awards was limited to the grounds set forth in CPLR article 75, and since none of the awards met or exceeded the statutory threshold sum of $5,000, de novo review was unavailable. Therefore, the individual complaints served by plaintiff seeking such relief did not state a viable cause of action, and the court was warranted in dismissing the consolidated actions upon plaintiff's motion for entry of a default judgment.

The relevant facts the court considered include a vehicle insured by IDS Property Casualty Insurance Company that was involved in a 2009 automobile accident. The owner and driver of the vehicle, along with three passengers, assigned their no-fault insurance benefits to certain medical providers who are the defendants in the case. The plaintiff moved for summary judgment declaring it was not obligated to pay these no-fault benefits to the defendants due to their failure to appear at an examination under oath twice. The defendant opposed this, arguing that they should be given a final opportunity to appear for an examination under oath. The main issue decided was whether the defendants' failure to comply with the condition precedent of appearing for an examination under oath precluded them from recovering the patient's no-fault benefits. The holding was that the decision of the Supreme Court was reversed and the plaintiff's motion for summary judgment was granted, remanding the case for the entry of a judgment declaring the plaintiff was not obligated to pay the subject no-fault benefits.

The relevant facts in Aetna Health Plans v Hanover Ins. Co. involved Aetna Health Plans, as the assignee of Luz Herrera, seeking payment of no-fault benefits from Hanover Insurance Company. However, the court found that Aetna was not a "health care provider" under the statute, but rather a health care insurer, and therefore not entitled to no-fault benefits. Additionally, the court ruled that the No-Fault Law provides a limited window of arbitration between no-fault insurers, but such language does not pertain to a health insurer like Aetna. The main issue decided was whether Aetna was entitled to maintain a claim against Hanover under the principle of subrogation or assert a breach of contract claim as an intended third-party beneficiary. The holding of the case was that Aetna cannot maintain a claim against Hanover under the principle of subrogation or assert a breach of contract claim, as it was not in privity of contract with Hanover and was not an intended third-party beneficiary of the contract.

The case concerned an arbitration award sought to be confirmed by Allstate Insurance Company against Fiduciary Insurance Company of America for $14,966.02, which related to a loss transfer claim arising from a 2008 motor vehicle accident. Allstate was seeking to recoup the amount it had paid in medical treatments for injuries sustained in the accident by one of its insured. Fiduciary challenged the arbitration award, alleging that the arbitrator exceeded her power, failed to consider new evidence proving liability of Allstate's driver, and improperly shifted the burden to Fiduciary to disprove damages. The court held that the arbitration award was rational in finding Fiduciary 50% liable for the accident and in dismissing Fiduciary's contention that Allstate's driver was 100% liable. However, the court found the arbitration award to be irrational and arbitrary in the determination of damages and remitted the matter to the arbitrator for a new determination. The court also denied Allstate's request for legal fees and held its request for interest and court costs in abeyance, pending a decision in accordance with its ruling. Ultimately, the court granted the petition to the extent that the determination of liability in the arbitration award was confirmed, but denied it in all other respects.

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.