No-Fault Case Law

The court considered that SB Chiropractic, P.C provided medical care to Eddie Rivera after a car accident in 2017. The court noted that SB Chiropractic, P.C forwarded ten bills to GEICO Insurance Co. for the medical care provided. GEICO partially paid or denied each of these bills. The court discussed the legal obligations set forth by no-fault insurance regulations for GEICO with regards to timely denial of claim forms. The main issue decided was whether the Plaintiff is entitled to summary judgment, based on the insufficiency of the denial of claim forms issued by GEICO. The holding was that the Plaintiff was not entitled to summary judgment, because GEICO's denial of claim forms were sufficient and ADmissible in court.

The court considered the fact that the insurer had paid the full monetary limits set forth in the policy, which meant that its duties under the contract of insurance had ceased. The issue at hand was whether an insurer can be required to pay in excess of the monetary limit of a no-fault insurance policy, and whether a defense that the coverage limits of the policy have been exhausted can be asserted by an insurer despite its failure to issue a denial of the claim within the 30-day period. The holding of the court was that an arbitrator's award directing payment in excess of the monetary limit of a no-fault insurance policy exceeds the arbitrator's power and constitutes grounds for vacating the award. The court also found that the insurer was not precluded by the regulations from paying other legitimate claims subsequent to the denial of the respondent's claims, and that the alleged defect in the insurer's proof could have been raised at the framed issue hearing. Additionally, the court held that the respondent, who had admitted in its papers that the assignor was a pedestrian, may not now claim that additional personal injury protection benefits are payable.

The relevant facts the court considered included the proceeding pursuant to CPLR article 75 to vacate an award of a master arbitrator dated April 10, 2018, which vacated an arbitration award in favor of the petitioner. The petitioner appealed from an order denying the petition to vacate the award. The main issue decided was whether the master arbitrator's determination could be overturned, and the holding of the case was that the order denying the petition was reversed, and the petition to vacate the award of the master arbitrator was granted. The matter was remitted to the Supreme Court, Nassau County for further proceedings consistent herewith. The court found that there was no rational basis to support the award of the master arbitrator and that the application of certain regulations was irrational, allowing the insurer to avoid statutory timeliness requirements.

The court considered the facts presented by the plaintiff insurer and the defendants Metro Pain Specialists, P.C. and Right Aid Medical Supply Corp. regarding the entitlement to no-fault benefits. The main issue decided was whether the plaintiff insurer complied with the time frames in scheduling the defendant Louis Melendez's independent medical examination (IME) as set forth in the no-fault implementing regulations. The holding of the court was that the plaintiff insurer failed to make a prima facie showing that it complied with the time frames in scheduling the IME, and therefore, the defendants Metro Pain Specialists, P.C. and Right Aid Medical Supply Corp. were entitled to no-fault benefits. The judgment of the Supreme Court, New York County was reversed, and the judgment vacated. The plaintiff did not provide evidence as to when it received the claims from Metro and Right Aid, and thus failed to establish that it scheduled the IME within the prescribed time frame.

The appellant in this case, American Transit Insurance Company, appealed from an order of the Supreme Court, Queens County, denying their motion for summary judgment dismissing the complaint in an action to recover no-fault benefits. The plaintiff, Healthplus Surgery Center, LLC, had commenced the action to recover assigned first-party no-fault benefits for medical services rendered. The defendant argued that the services lacked medical necessity and the amount sought exceeded the amount permitted by the applicable fee schedule. The court found that the defendant failed to establish, prima facie, that the services provided were not medically necessary but did establish, prima facie, that the bills for the services provided were in excess of the proper fee schedule. As a result, the order was modified to grant the defendant's motion for summary judgment dismissing those portions of the complaint that sought reimbursement greater than the amounts determined by the defendant's expert.

The main issue in this case was whether the plaintiff, Medtech Medical Supply, Inc., as the assignee of Abul Azad, had the standing to maintain an action to recover first-party no-fault benefits for supplies provided to the assignor as a result of a motor vehicle accident that occurred on June 11, 1998. The defendant, Country-Wide Insurance Company, argued that the plaintiff lacked the capacity to maintain the action and collect on the judgment, as the plaintiff had been dissolved by the State of New York in 2001 and had failed to wind up its affairs within a reasonable time. The court considered the provisions of Business Corporation Law §§ 1005 and 1006, which allow a dissolved corporation and its directors, officers, and shareholders to continue to function for the purpose of winding up the affairs of the corporation. The court held that the plaintiff had the capacity to seek entry of judgment and maintain the action as part of the winding up of its business affairs, and that defendant's motion to vacate the judgment and dismiss the complaint should have been denied. The court also found that the basis for vacating the judgment pursuant to CPLR 5015 (a) (4) was improper, and remanded the matter to the Civil Court to determine plaintiff's pending motion.

The relevant facts that the court considered were that the plaintiff, a medical provider, was seeking to recover first-party no-fault benefits on behalf of an assignor who had failed to appear for examinations under oath (EUOs) as required by the insurance company. The main issue decided by the court was whether the assignor's failure to appear at the EUOs constituted a failure to comply with a condition precedent to coverage. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted, as the evidence presented by the defendant, including an affidavit and certified transcripts of the EUOs, demonstrated that the assignor had failed to appear for the EUOs, thereby failing to comply with a condition precedent to coverage. As a result, the order was affirmed by the court.

The case involved Charles Deng Acupuncture, P.C. attempting to recover assigned first-party no-fault benefits from Titan Insurance Co. The dispute arose over whether Deng Acupuncture had appeared for examinations under oath (EUOs) as required. The judgment dismissed the complaint after a nonjury trial that focused on this issue. The court held that transcripts of "bust" statements by the defendant's attorney regarding Deng Acupuncture's nonappearances at EUOs should not have been admitted as evidence. As a result, the court found that the defendant did not sustain its burden of proving that the plaintiff had failed to appear for the EUOs, and reversed the judgment, remitting the matter to the Civil Court for the entry of a judgment in favor of the plaintiff in the sum of $2,226.41, following a calculation of statutory no-fault interest and an assessment of attorney's fees.

The main issues decided in this case were whether the EUO scheduling letters were properly mailed to the plaintiff's assignor and whether the plaintiff's assignor had failed to appear for scheduled examinations under oath (EUOs). The relevant facts considered by the court included the timely mailing of the EUO scheduling letters by the defendant and the failure of the plaintiff to appear for the EUOs as scheduled. The court found that the letters had been properly mailed to the plaintiff's assignor based on the matching address on the NF-3 forms provided to the defendant. As a result, the court held that the defendant had established a prima facie case that the letters had been properly mailed and that the plaintiff's opposition papers failed to rebut this showing. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted and the order denying the motion was reversed.

The court considered the case of American Transit Insurance Company against Jose A Marte Lopez and several medical provider defendants. American Transit brought this action for a declaratory judgment that it is not required to pay no-fault benefits to Lopez or to Lopez's medical provider assignees, based on Lopez's failure to appear for independent medical examinations (IMEs) scheduled under the terms of the no-fault insurance policy. American Transit moved for summary judgment against the remaining answering defendants, arguing that it complied with procedural and timeliness requirements for no-fault claims and was entitled to a declaratory judgment. The court ultimately denied American Transit's motion for summary judgment, as it found that American Transit had not provided evidence that it timely requested the IME at issue, which was required to obtain the requested declaratory judgment. The court also noted that the arguments made by American Transit had previously been rejected in similar cases, and the recent decisions of the Appellate Division, First Department further supported the denial of American Transit's motion for summary judgment.