No-Fault Case Law

The court considered the facts of a case brought by B & Y Surgical Supplies, Inc. as the assignee of Rosa Perez, seeking to recover assigned first-party no-fault benefits from Geico General Ins. Co. The main issue was whether Geico General Ins. Co. had timely mailed denials of the two claims at issue on the ground of lack of medical necessity. The holding of the court was that while the papers submitted by Geico General Ins. Co. were sufficient to establish that they had timely mailed denials of the claims, there were triable issues of fact as to the medical necessity of the supplies provided. As a result, the court granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment and modified the order by denying the plaintiff's motion for summary judgment as well.

The relevant facts considered by the court in this case involved a dispute between Flatbush Chiropractic, P.C. and State Farm Mutual Automobile Ins. Co. regarding the former's failure to comply with scheduled examinations under oath (EUOs) as a condition precedent to coverage. The main issue decided by the court was whether State Farm Mutual Automobile Ins. Co. had proven that it had mailed the EUO scheduling letters and denial of claim forms in a timely manner, and whether Flatbush Chiropractic, P.C. had failed to respond to the EUO requests. The holding of the court was that the affidavits submitted by State Farm established that the EUO scheduling letters and denial of claim forms had been timely mailed, and since Flatbush Chiropractic, P.C. did not claim to have responded in any way to the EUO requests, its objections regarding the requests would not be heard. Therefore, the court affirmed the order in favor of State Farm Mutual Automobile Ins. Co.

The court considered the denial of claim forms, which denied the claims at issue on the grounds of lack of medical necessity, and sworn peer review reports that set forth a factual basis and medical rationale for the doctor's determination that there was a lack of medical necessity for the MRIs at issue. The main issue was whether the services at issue were medically necessary. The court held that the denial of claim forms had been timely mailed and that the sworn peer review reports were sufficient to establish a lack of medical necessity for the MRIs at issue. Additionally, the court found that the affirmations by a medical doctor were sufficient to raise a triable issue of fact as to whether the services at issue were medically necessary, and therefore, granted the defendant's motion for summary judgment dismissing the complaint and denied the plaintiff's cross motion for summary judgment.

The case involved a dispute between Baybenson Chiropractic, LLC, as assignee of Simeon Johnson, and Clarendon National Insurance over the denial of first-party no-fault benefits. Clarendon National Insurance had denied the claims based on a lack of medical necessity and submitted a sworn peer review report and an independent medical examination (IME) report to support their determination. In response, Baybenson Chiropractic, LLC submitted an affidavit by a chiropractor, which failed to rebut the conclusions of the peer reviewer or the chiropractor who had performed the IME. The court ultimately reversed the order of the Civil Court, granting defendant's motion for summary judgment dismissing the complaint. The main issue decided was whether there was sufficient evidence to support Clarendon National Insurance's denial of the claims based on lack of medical necessity, and the holding was that the denial was justified based on the evidence presented.

The relevant facts for this legal case are that the plaintiff, Six Star Supply, Inc., initiated an action to recover assigned first-party no-fault benefits in October 2009, and the defendant, Praetorian Ins. Co., defaulted. More than a year later, the plaintiff moved for leave to enter a default judgment against the defendant, and the defendant cross-moved to dismiss the complaint pursuant to CPLR 3215 (c). The main issue decided by the court was whether the plaintiff offered a reasonable excuse for the delay in moving for leave to enter a default judgment, and whether the plaintiff demonstrated that the complaint was meritorious. The holding of the case was that as the plaintiff failed to offer any excuse for its delay in moving for leave to enter a default judgment, the court found that dismissal of the complaint was required pursuant to CPLR 3215 (c). Therefore, the court reversed the order, denied plaintiff's motion, and granted the defendant's cross motion.

The court considered the denial of the plaintiff's motion for summary judgment and the granting of the defendant's cross motion for summary judgment in a case involving a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the examination under oath scheduling letters and denial of claim form had been timely mailed, and whether the plaintiff had failed to appear at the scheduled examinations under oath. The court found that the affidavits submitted by the defendant established that the scheduling letters and denial of claim form had been timely mailed, and that the plaintiff had failed to appear at the scheduled examinations under oath, which was a condition precedent to the insurer's liability on the policy. The judgment was affirmed in favor of the defendant insurance company.

The main issue in this case was whether the Civil Court was correct in denying the plaintiff's motion for summary judgement and granting the defendant's cross motion for summary judgement in a lawsuit by a provider to recover assigned first-party no-fault benefits. The Court found that the affidavit of the defendant's claims examiner, submitted in support of its cross motion, failed to address certain of the plaintiff's claims and failed to substantiate the fee schedule defense which was the stated basis for one denial. The court reversed the judgment, vacated the part of the order that granted the defendant's cross motion for summary judgement, and denied the defendant's cross motion. Therefore, the decision was in favor of the plaintiff, and the judgment was reversed and the defendant's cross motion was denied.

The relevant facts the court considered in this case were that the defendant had mailed independent medical examination (IME) scheduling letters to the plaintiff's assignor, but to the wrong address. The main issue decided was whether the defendant had properly scheduled the IMEs and whether the assignor had failed to appear. The holding of the case was that the defendant failed to demonstrate that the IMEs had been properly scheduled, as the zip code on the mailing logs did not match the zip code provided by the plaintiff's assignor. Therefore, the court affirmed the order granting the plaintiff's motion for summary judgment and denying the defendant's cross motion for summary judgment.

The court considered the case of Quality Psychological Services, P.C. as the assignee of Phillip Williamson, who was seeking to recover assigned first-party no-fault benefits from Travelers Home & Marine Insurance Company. The main issue decided was whether the defendant had failed to prove that the plaintiff's assignor had not appeared for independent medical examinations (IMEs). The court held that the affidavit executed by the operations manager of SIGNET Medical Services, P.C. was not sufficient to raise a triable issue of fact as to whether plaintiff's assignor had appeared for the scheduled IMEs. The court found that the defendant failed to demonstrate that the plaintiff's assignor actually failed to comply with a condition precedent to coverage by failing to appear for duly scheduled IMEs, and therefore affirmed the order granting the plaintiff's motion for summary judgment.

In the case of Kew Garden Imaging v. State Farm Mutual Automobile Ins. Co., the main issue was whether the services at issue were medically necessary. The trial court precluded the defendant's medical witnesses from testifying on the ground that they could not testify as to the contents of the medical records they had reviewed in preparing their peer reviews. The Appellate Term, Second Department, held that the defendant's doctors should have been permitted to testify and that a new trial was required. The court also noted that the trial involved a claim for $60.70, to which the defendant had apparently raised a workers' compensation fee schedule defense. The entire case was remitted for a new trial and the judgment of the trial court was reversed.