No-Fault Case Law

The court in this case considered an action to recover no-fault benefits under a policy of automobile insurance. The plaintiff, Westchester Medical Center, as assignee of Arianna Thrasher, appealed from an order of the Supreme Court that denied its motion for summary judgment on its first cause of action. The court held that the plaintiff made a prima facie showing of entitlement to judgment by submitting evidence that the prescribed billing form was received by the respondent insurer and failed to pay or deny the claim within the requisite 30-day period. The court also held that the respondent failed to raise a triable issue of fact in opposition to the appellant's prima facie showing. The respondent's contention of a complete absence of coverage that could be asserted as a basis for disclaimer was deemed improper as it was raised for the first time on appeal. The court reversed the order, granting the plaintiff's motion for summary judgment on its first cause of action.

The court considered the fact that the plaintiff provider was seeking to recover assigned first-party no-fault benefits from the defendant insurance company. The main issue decided was whether the defendant had timely and properly denied the claims at issue on the ground that the plaintiff had failed to comply with a condition precedent to coverage by failing to appear for duly scheduled examinations under oath. The holding of the court was that the defendant had proven that it had mailed its EUO scheduling letters and denial of claim forms in accordance with its standard office practices and procedures, and that the plaintiff's objections regarding the EUO requests would not be heard since the plaintiff did not claim to have responded in any way to the EUO requests. Therefore, the court affirmed the order of the Civil Court granting the defendant's motion for summary judgment dismissing the complaint.

The court considered a case in which Alev Medical Supply, Inc., as the assignee of Kecia Daniely, appealed the dismissal of their complaint seeking first-party no-fault benefits from Government Employees Insurance Company. The trial was limited to the issue of the defendant's defense of lack of medical necessity, and ultimately, the court found in favor of the defendant, dismissing most of the plaintiff's claims. The only remaining claim was for the recovery of $330 for a massager and a Thermophore. On appeal, plaintiff raised evidentiary objections, specifically challenging the admissibility of defendant's doctor's testimony as hearsay. However, the court affirmed the judgment, ruling that the Civil Court properly overruled plaintiff's hearsay objection and that the plaintiff's remaining contentions lacked merit. Therefore, the judgment was affirmed in favor of the defendant.

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.