No-Fault Case Law

The main issue in this case was whether the defendant, Redland Insurance Company, had timely and properly denied the plaintiff's claims for first-party no-fault benefits based on a lack of medical necessity. The court considered a sworn peer review report submitted by the defendant, which provided a factual basis and medical rationale for the determination that there was a lack of medical necessity for the services at issue. The plaintiff, Intuitive Chiropractic, P.C. as Assignee of Ruth Santamaria, failed to rebut the defendant's prima facie showing. As a result, the court held that the defendant's cross motion for summary judgment dismissing the complaint should be granted. Therefore, the holding of the case was that the defendant was entitled to summary judgment dismissing the complaint, and the order of the Civil Court denying the defendant's cross motion was reversed.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, denying the plaintiff's motion for summary judgment in a case involving the recovery of assigned first-party no-fault benefits. The main issue decided was whether the denial of the plaintiff's motion for summary judgment was appropriate, and the court ultimately reversed the order and granted the plaintiff's motion for summary judgment. The holding of the case was that the matter was remitted to the Civil Court for a calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106 and the regulations promulgated thereunder. The Appellate Term, Second Department, made the decision on August 26, 2013.

The relevant facts the court considered in this case were that a provider was seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the provider had established the fact and amount of the loss sustained, and whether there were triable issues of fact as to the medical necessity of the service provided. The holding of the case was that the court affirmed the order, finding that the plaintiff had indeed established the fact and amount of the loss sustained, and that there were triable issues of fact as to the medical necessity of the service provided. The order directed that a trial be held on the issue of medical necessity.

The relevant facts considered by the court were that the plaintiff, Canarsie Chiropractic, P.C., was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The main issue decided was whether the plaintiff had failed to comply with a condition precedent to coverage by not appearing for scheduled examinations under oath (EUOs). The court affirmed the order of the Civil Court, granting State Farm's motion for summary judgment dismissing the complaint, as the affidavits submitted by State Farm established that the EUO scheduling letters and denial of claim forms had been timely mailed. The holding of the case was that since the plaintiff did not respond in any way to the EUO requests, their objections regarding the EUO requests would not be heard, and therefore discovery relevant to the reasonableness of the EUO requests was not necessary to oppose the motion.

The main facts of the case are that Queens Integrated Medical Care P.C. brought a lawsuit against New York Central Mutual Fire Insurance Company, in relation to a no-fault claim for physical therapy and related services. The main issue considered by the court was whether there was a triable issue as to the medical necessity of the physical therapy and related services, due to conflicting medical expert opinions. The holding of the court was that the conflicting medical expert opinions presented by the parties were sufficient to raise a triable issue as to the medical necessity of the services, and therefore the motion for summary judgment dismissing the complaint was denied in part.

The relevant facts in the case include that the plaintiff, Eagle Surgical Supply, Inc., sought to recover first-party no-fault benefits. The defendant, AIG Insurance Co., denied the benefits on the basis that the plaintiff and its assignor had not appeared for examinations under oath. The Civil Court granted summary judgment in favor of the plaintiff, but the defendant obtained a declaratory judgment in a Supreme Court action stating that the defendant had no duty to defend or indemnify the plaintiff and its assignor due to their failure to appear for an examination under oath. The main issue was whether the plaintiff was seeking to relitigate the same claims or causes of action that were decided in the prior litigation, and if the doctrine of res judicata should apply. The holding was that since the declaratory judgment did not apply to the incident date of the plaintiff's claim, the plaintiff was not seeking to relitigate the same transaction or series of transactions, and thus the order denying the defendant’s motion to vacate the judgment was affirmed.

The relevant facts considered in this case included a 2007 motor vehicle accident in which the plaintiff's assignor sustained injuries, as well as a subsequent declaratory judgment and preclusion order. The main issue decided in this case was whether a prior declaratory judgment had res judicata effect and barred the plaintiff from recovering assigned first-party no-fault benefits. The holding of this case was that the conditional preclusion order did not preclude the court from giving res judicata effect to the declaratory judgment, and therefore the plaintiff's motion for summary judgment was denied and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The court considered the issue of whether the defendant's cross motion for summary judgment dismissing the complaint should be granted in a case by a provider to recover first-party no-fault benefits. The court found that the defendant had established its prima facie entitlement to summary judgment by submitting peer review reports that showed a lack of medical necessity for the services at issue. The plaintiff did not challenge this finding or provide any rebuttal evidence. As a result, the defendant's cross motion for summary judgment was granted. Additionally, the court directed the attorneys for the plaintiff to show cause as to whether sanctions and costs should be imposed against them for submitting a frivolous brief. Therefore, the court reversed the lower court's order, granted the defendant's cross motion for summary judgment, and ordered the plaintiff's attorneys to show cause regarding potential sanctions and costs.

The court considered the case of Promed Durable Equipment, Inc. as the Assignee of Luis Abreu v GEICO Insurance. The main issue decided was whether the supplies at issue, for which plaintiff was seeking first-party no-fault benefits, were medically necessary. The holding of the case was that defendant's cross motion for summary judgment dismissing the complaint was granted, as defendant had established its prima facie entitlement to summary judgment by submitting peer review reports that demonstrated a lack of medical necessity for the services at issue. The court also directed the plaintiff's attorney and counsel for the defendant to show cause as to why sanctions and costs should not be imposed against them, due to the inadequacy of respondent's appellate argument and undignified conduct. The order denying defendant's cross motion for summary judgment was reversed, and the case was decided in favor of the defendant.

The case involved a dispute between Promed Durable Equipment, Inc. and GEICO Insurance over the reimbursement of medical supplies provided, with the main issue being whether the supplies were medically necessary. The court found that the submission of bills and the fact and amount of the loss had been established for all purposes in the action. The court determined that plaintiff had raised a triable issue of fact as to whether certain supplies were medically necessary, and denied defendant's motion for summary judgment on those supplies. However, the court granted defendant's motion for summary judgment on claims for supplies furnished on December 24, 2008, as the plaintiff did not refute the peer review report's determination of lack of medical necessity. The court also directed the defendant's counsel to show cause as to why sanctions and costs should not be imposed for engaging in frivolous conduct in the appeal. Ultimately, the court affirmed in part and modified in part the lower court's order, and directed the parties to file affidavits or affirmations regarding potential sanctions and costs.