No-Fault Case Law

The case of American Tr. Ins. Co. v Lucas involved two separate actions in which the plaintiff, American Transit Insurance Company, sought declarations of non-coverage for no-fault benefits against defendant-respondent Sky Acupuncture, P.C. The injured claimants in both cases had failed to attend duly scheduled medical exams, which according to the court voided the policy. The Appellate Division, First Department, determined that plaintiff owed no coverage obligation to Sky Acupuncture, P.C. for no-fault benefits for the injured claimants, as the failure to attend the scheduled medical exams was an absolute coverage defense. The court relied on competent evidence that the notices scheduling the claimants' medical examinations had been mailed and the failure of the injured claimants to appear was established through sworn affidavits of the examining physician and his employee. The presumption of proper mailing was supported by the evidence and the failure of the claimants to attend the medical exams was found to be sufficient grounds for the plaintiff to retroactively deny all claims.

The case involves George Dinstber III and Allstate Insurance Company. Dinstber notified Allstate in January 2002 of injuries sustained in a motor vehicle accident and Allstate denied his no-fault claim, leading to Dinstber filing an action in which he asserted claims of breach of contract and tort, with a request for punitive damages. The court granted Allstate's motion for partial summary judgment, dismissing Dinstber's tort claim and denying his cross motion for, among other things, leave to amend the complaint. The court held that although punitive damages may be recoverable if necessary to vindicate a public right, Dinstber's claims did not allege a breach of duty distinct from Allstate's contractual obligations. The court also ruled that Dinstber's motion for leave to amend the complaint was properly denied as he failed to establish that the proposed amendment is not plainly without merit.

The main issue in this case was whether the defendant-insurer was entitled to summary judgment dismissing the complaint made by Premier Health Choice Chiropractic, P.C. The court considered the fact that the defendant made a prima facie showing of entitlement to judgment as a matter of law by demonstrating that it timely denied the plaintiff's first-party no-fault claims based on a sworn independent medical examination (IME) report of its examining chiropractor. The court held that the unsworn doctor's report submitted with the plaintiff's attorney's affirmation was without probative value and did not meaningfully refer to, let alone rebut, the contrary findings made by the defendant's peer reviewer. Therefore, the court reversed the order of the Civil Court of the City of New York and granted the defendant's motion for summary judgment, directing the clerk to enter judgment accordingly.

The court considered the denial of the defendant-insurer's motion for summary judgment in a case to recover assigned first-party no-fault benefits. The main issue decided was whether the peer review report and affidavit submitted by the defendant's chiropractor provided a sufficient basis to conclude that the medical supplies at issue were not medically necessary. The court held that the peer reviewer's assertion was insufficient to meet defendant's burden of eliminating all triable issues as to medical necessity. Additionally, the court found that the plaintiff's submission of an affidavit prepared by the assignor's treating chiropractor was sufficient to raise a triable issue as to medical necessity. Therefore, the order denying the defendant's motion for summary judgment was affirmed.

The court considered whether the defendant's motion for summary judgment dismissing the complaint was justified. The main issue was whether the plaintiff had failed to comply with a condition precedent to coverage by failing to appear for scheduled examinations under oath (EUOs). The court held that the defendant had established through affidavits that the EUO scheduling letters and denial of claim forms had been timely mailed. Additionally, since the plaintiff did not respond in any way to the EUO requests, their objections regarding the requests were not heard. Therefore, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The court considered the issue of whether the defendant-insurer's verification letters were timely and properly mailed to the plaintiff in a first-party no-fault action. The main issue decided was whether the plaintiff raised a triable issue sufficient to withstand summary judgment dismissal. The court held that the affidavit of an employee of a third-party biller, who had no personal knowledge of the date the purported "verification compliance" letter was mailed to the defendant, and described in only the most general terms her office's mailing practices and procedures, was insufficient to raise an issue of fact. Therefore, the defendant was entitled to summary judgment dismissing the claim as premature.

The relevant facts in this case are that the defendant-insurer made a prima facie showing of entitlement to summary judgment dismissing the action for first-party no-fault benefits by establishing that it timely and properly mailed the notices for independent medical examinations (IMEs) to the plaintiff's assignor, and that the assignor failed to appear. The main issue decided by the court was whether the defendant made a sufficient showing to be entitled to summary judgment. The court ultimately held that the defendant made a prima facie showing of entitlement to summary judgment by establishing that it timely and properly mailed the notices for IMEs to the plaintiff's assignor, and that the assignor failed to appear. The court further held that the plaintiff did not raise a triable issue with respect to the assignor's nonappearance or as to the mailing or reasonableness of the underlying notices. The defendant's motion for summary judgment dismissing the complaint was granted.

The court considered a provider's attempt to recover first-party no-fault benefits, with the defendant arguing lack of medical necessity as a defense. The main issue was whether the peer review report relied upon by the defendant was admissible, as the plaintiff argued that the signature on the report was stamped and therefore inadmissible. The court held that the plaintiff's assertion, without any indication as to why they believed the signature was stamped, was insufficient to raise an issue of fact, and therefore affirmed the judgment in favor of the defendant.

The court considered the evidence provided by the defendant, including affidavits from a manager of Crossland Medical Review Services, Inc., an affidavit from the defendant's litigation examiner, and affidavits from the doctors scheduled to perform the independent medical examinations (IMEs). The main issue was whether the defendant had established that the plaintiff's assignor failed to appear for the scheduled IMEs and whether the denial of claim forms had been timely mailed to the plaintiff's address. The holding of the case was that the court reversed the order of the Civil Court and granted the defendant's motion for summary judgment dismissing the complaint. The court found that the evidence provided by the defendant was sufficient to establish that the plaintiff's assignor had failed to appear for the scheduled IMEs and that the denial of claim forms had been timely mailed to the plaintiff's address.

The relevant facts the court considered in this case included the denial of a claim form by the defendants, who were insurance companies, and the late submission of the plaintiff's claims. The main issue decided was whether the defendants were justified in denying the claim and whether the plaintiff had provided a reasonable justification for the late submission. The holding of the case was that the defendants' denial of the claim form was timely and adequately advised the plaintiff of the basis for the denial, as well as the potential for excusing the late submission if a reasonable justification was provided. As the plaintiff failed to offer any explanation for the delay, the court reversed the original order and granted the defendants' motion for summary judgment dismissing the complaint.