No-Fault Case Law

The court considered a case involving a provider seeking to recover assigned first-party no-fault benefits against an insurance company. The insurance company appealed an order that granted the provider's motion for summary judgment on all claims except for one and denied the insurance company's cross motion seeking summary judgment on the same claims. The insurance company submitted evidence to show that it had timely denied claim forms and fully paid the provider for certain services. It also submitted an independent medical examination (IME) report that concluded there was no medical necessity for additional services. The provider failed to meaningfully rebut the conclusions in the IME report. The court held that the insurance company was entitled to summary judgment dismissing the provider's claims for services based on the evidence presented, and therefore reversed the lower court's order.

The court considered a cross motion for summary judgment by defendant GEICO Insurance Company seeking to dismiss claims for services rendered by plaintiff Gentle Care Acupuncture, P.C. The main issue decided was whether GEICO had timely denied the claims and whether there was a lack of medical necessity for the services. The court reversed the order of the Civil Court and granted the branches of the defendant's cross motion seeking summary judgment. It was held that GEICO had timely denied the claims for services rendered by Gentle Care Acupuncture, P.C. based on exceeding the workers' compensation fee schedule, and that there was a lack of medical necessity for further acupuncture services as determined by an independent medical examination performed by defendant's acupuncturist. Therefore, GEICO's cross motion for summary judgment dismissing the claims was granted.

The court considered the facts of an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the doctrine of collateral estoppel barred the plaintiff from relitigating the issue of whether the injuries arose from an insured incident. The holding of the court was that the defendant established that the issue was identical to the issue previously decided by the jury in an earlier personal injury action. Therefore, the plaintiff was ineligible to receive reimbursement of no-fault benefits because the injuries did not result from an insured incident. The order was affirmed.

The case involved a medical provider seeking to recover no-fault benefits from an insurance company. The insurance company appealed an order from the Civil Court that denied its motion to strike the complaint due to the plaintiff's failure to comply with a discovery stipulation. The stipulation, which was not "so-ordered," provided that if the plaintiff failed to respond to the defendant's outstanding discovery demands within 30 days, it would be precluded from offering evidence or contesting any defense as to the items demanded but not provided. The court found that since the stipulation was subscribed by the attorneys, it was an independent contract subject to contract law principles. As the plaintiff failed to respond to the defendant's discovery demands, the court decided in favor of the insurance company, reversing the previous order and granting the motion to strike the complaint.

The main issue in this case was whether the supplies provided by the plaintiff, Yklik, Inc. as Assignee of TREVARE WHITE, were medically necessary and therefore covered under a no-fault benefits policy. The court considered the fact that the defendant, Electric Insurance Co., had submitted affirmed peer review reports with factual basis and medical rationale for their determination that there was a lack of medical necessity for the supplies provided. In opposition, the plaintiff submitted an affirmation from a doctor, which did not meaningfully refer to, let alone rebut, the conclusions set forth in the peer review reports. The court held that as the plaintiff did not challenge the finding that the defendant was otherwise entitled to judgment, the defendant's cross motion for summary judgment dismissing the complaint was granted. Therefore, the order denying the defendant's cross motion for summary judgment was reversed and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The court considered the fact that the defendant was first notified of the accident through the receipt of the claimant's form, which was dated September 25, 2007, even though the accident occurred on July 11, 2007. The defendant denied the plaintiff's claims on the basis that proper notice of the claim in writing had not been received within 30 days from the date of the accident. The main issue decided was whether the plaintiff had provided sufficient proof to demonstrate a triable issue of fact regarding the timely notice of the accident. The holding of the case was that the plaintiff had failed to provide any proof to demonstrate the existence of a triable issue of fact and had also failed to provide a reasonable justification for the lateness of the notice. Therefore, the District Court had properly granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered the issue of whether an insurer had established that a provider failed to appear for scheduled examinations under oath (EUOs) by mailing denial of claim forms. The provider argued that an insurer must advise the applicant that the failure to appear for an EUO will be excused where reasonable justification for nonappearance is provided. The court, however, found no basis in the regulations for imposing such a requirement. The main issue in this case was whether the insurer had proven that the provider failed to appear for scheduled EUOs, and the court held that the insurer had done so. As a result, the court affirmed the judgment in favor of the insurer.

The main issue in this case was whether State Farm Mutual Automobile Insurance Company was entitled to summary judgment in an action by a medical provider to recover first-party no-fault benefits. The court considered whether State Farm had established that it timely mailed examination under oath (EUO) scheduling letters and denial of claim forms. In support of its motion for summary judgment, State Farm submitted affidavits by its special investigative unit team manager, mail room employee and bulk mail vendor, which were sufficient to establish that the EUO scheduling letters and denial of claim forms had been timely mailed. The court held that an appearance at an EUO is a condition precedent to an insurer's liability on a policy, and as such, State Farm was entitled to summary judgment. Therefore, the court affirmed the order granting State Farm's motion for summary judgment.

In this case, BR Clinton Chiropractic, P.C. was trying to recover first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The court considered whether the insurance company had failed to pay or deny the claims at issue within the required 30-day period and whether the company had issued timely denial of claims that were conclusory, vague, or without merit as a matter of law. The main issues decided were whether the affidavit submitted by the billing supervisor was sufficient to establish that the insurance company failed to pay or deny the claims in a timely manner, and whether the company proved that the initial verification and follow-up verification requests were timely mailed to the plaintiff's assignor. The holding of the case was that the judgment was reversed, and the branches of plaintiff's motion seeking summary judgment were vacated, denying those branches of the motion. The court also found that the insurance company failed to establish that the 30-day claim determination period was tolled, and as a result, the denial of claim forms were not timely.

The main issue in this case was whether the defendant, State Farm Mutual Automobile Ins. Co., was entitled to summary judgment dismissing the complaint brought by Mega Supplies Billing, Inc. as an assignee of Frederick Bianchi to recover assigned first-party no-fault benefits. The court considered whether the defendant had established that it had timely mailed examination under oath (EUO) scheduling letters and denial of claim forms. In support of its motion for summary judgment, the defendant submitted affidavits by its litigation examiner and its special investigative unit and mail room employees, which were found to be sufficient to establish that the EUO scheduling letters and denial of claim forms had been timely mailed. Since an appearance at an EUO is a condition precedent to an insurer's liability on a policy, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.