No-Fault Case Law

The main issues in this case involved the denial of first-party no-fault benefits by the defendant and the plaintiff's appeal to compel the defendant to produce its Special Investigation Unit (SIU) file. The court held that the defendant failed to demonstrate that it had decided to deny the plaintiff's claims prior to commencing its investigation, making the contents of the defendant's SIU file discoverable. Additionally, the court ruled that the defendant was not entitled to any discovery regarding whether the plaintiff was in compliance with applicable state or local licensing laws, as this issue was previously resolved in a stipulation and not actually litigated. However, the court also determined that the plaintiff was obligated to produce the requested information and that the defendant was entitled to depose specific individuals. Therefore, the order was modified to grant the branch of the plaintiff's motion seeking to compel the defendant to produce its SIU file.

The relevant facts the court considered in the case were that Bright Medical Supply Co. was seeking to recover first-party no-fault benefits, but the defendant had denied the claims based on the plaintiff's failure to appear for scheduled examinations under oath. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The holding of the case was that the defendant's motion was properly denied because they failed to submit proof from someone with personal knowledge of the plaintiff's nonappearance for the examinations under oath. Therefore, the order denying the defendant's motion was affirmed.

The court considered the fact that the defendant, Tri State Consumer Ins. Co., had moved for summary judgment dismissing the complaint brought by Bright Medical Supply Co. as the assignee of Roshel Pakanayev, alleging that it had never received the claim at issue. The main issue decided was whether the plaintiff's opposition to the motion was sufficient to demonstrate proof of proper mailing of the claim form, which would give rise to a presumption of receipt. The court held that the affidavit of defendant's claims representative established that the defendant had never received the claim in question from the plaintiff, and that not only was the plaintiff's opposition to the defendant's motion insufficient to demonstrate proof of proper mailing of the claim form, but the defendant also demonstrated that the address to which the plaintiff had allegedly mailed the claim, a post office box in Philadelphia, was not the defendant's address. Therefore, the court reversed the previous order and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the denial of a claim for assigned first-party no-fault benefits by Quality Health Products for their assignors Lony Beatris, Francois Stevenson, and Milord Guerson. Defendant GEICO General Insurance Company established the mailing of the denials and the lack of medical necessity for the supplies provided to the assignors. Quality Health Products did not submit any medical evidence to rebut GEICO's prima facie showing of a lack of medical necessity. The court affirmed the judgment which granted the branches of defendant's cross motion seeking summary judgment dismissing the portion of the complaint that sought to recover upon claims for the assignors based on a lack of medical necessity.

According to the fact pattern of the case, a professional corporation provided MRI services for patients injured in car accidents. The corporation then submitted the assigned claims for reimbursement to the responsible insurers and self-insurers, including the defendant, Progressive Insurance Company (Progressive), which after failing to pay the claims, led to the commencement of a lawsuit. The total amount sought for the claims in all of these actions was approximately $18 million. The defense asserted was that the professional corporation was ineligible to recover no-fault benefits due to its failure to comply with licensing requirements. After a joint trial, a jury returned a verdict in favor of all defendants, and the Civil Court denied the plaintiff's motion to set aside the verdict. The Holding was that the court affirmed the judgment of the Civil Court without costs, in favor of the defendant, Progressive.

The relevant facts considered by the court were that a chiropractor was seeking to recover assigned first-party no-fault benefits for services rendered to an individual's spine, and the insurance company had denied the claims on the grounds of lack of medical necessity based on an independent medical examination (IME). The main issue was whether the chiropractic services at issue were medically necessary. The court found that the insurance company had made a showing that the treatment was not medically necessary, and therefore the burden was on the chiropractor to demonstrate, by a preponderance of the credible evidence, that the treatment was indeed necessary. Since the chiropractor did not provide any evidence, the court held that a finding that the individual's condition had worsened after the IME would be speculative, at best. Therefore, the judgment was reversed and the matter was remitted to the District Court for the entry of judgment in favor of the insurance company, dismissing the complaint.

The main issues in this case were whether the medical services provided by the plaintiff were medically necessary and whether the defendant-insurer was entitled to summary judgment. The court considered the chiropractor's sworn peer review report, which concluded that the services were not medically necessary according to the standards of protocol followed by the National Academy of MUA physicians. The court also considered the unsworn operative reports of the plaintiff's principal, which were found to be without probative value. The court ultimately held that the defendant-insurer made a prima facie showing of entitlement to judgment as a matter of law, and therefore granted the motion for summary judgment and dismissed the complaint.

The relevant facts the court considered in SS Med. Care, P.C. v Nationwide Ins. involved an action by a provider to recover assigned first-party no-fault benefits. The appellant, SS Medical Care, P.C., appealed from an order that granted the branches of the defendant's motion seeking summary judgment dismissing the second, third, fourth, and fifth causes of action. Defendant denied the claims at issue on the ground that the plaintiff's assignor had failed to attend scheduled examinations under oath (EUOs) and independent medical examinations (IMEs). The main issues decided were whether the defendant demonstrated its entitlement to summary judgment based on the assignor's failure to appear at scheduled EUOs and IMEs, and whether the defendant's submissions were sufficient to establish that the requests for EUOs and IMEs had been properly addressed and mailed. The holding of the case was that the order, insofar as appealed from, was reversed, without costs, and the branches of defendant's motion seeking summary judgment dismissing the second, third, fourth, and fifth causes of action were denied.

The relevant facts the court considered included the plaintiff's motion for summary judgment and the defendant's opposition on the basis of non-compliance with discovery demands. The main issue decided was whether the plaintiff had established its entitlement to summary judgment in a case to recover assigned first-party no-fault benefits. The holding of the case was that the plaintiff had indeed established its entitlement to summary judgment, as the defendant failed to show that additional discovery would lead to relevant evidence, and also failed to establish that it had timely denied the claim, precluding it from raising certain defenses. Therefore, the order granting the plaintiff's motion for summary judgment and denying the defendant's cross motion to compel discovery was affirmed.

The main issue in this case was whether the plaintiff, Sigma Psychological, P.C., was eligible to recover assigned first-party no-fault benefits as a fraudulently incorporated professional corporation. The court considered the defendant's detailed and specific reasons for its belief that the plaintiff may be ineligible for these benefits, as well as the plaintiff's failure to comply with court-ordered disclosure related to this defense. The court found that the defendant had established that the plaintiff had willfully and contumaciously refused to fully comply with discovery requests, even after agreeing to do so by court orders, and that there was no reasonable excuse for this failure to comply. The court ultimately affirmed the order granting the defendant's motion to dismiss the complaint pursuant to CPLR 3126.