No-Fault Case Law

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.

The main issue in this case was whether the defendant insurer's motion to strike the notice of trial and compel discovery should have been granted or denied. The court considered the plaintiff's appeal from the order of the Civil Court of the City of New York, Bronx County, which granted the defendant's motion. The court held that the defendant's demands for discovery pertaining to its affirmative defense that another insurance carrier was primarily liable were immaterial and improper. The court also determined that the defendant had not set forth any case-specific allegations in support of its defense that the plaintiff was fraudulently incorporated. Therefore, the defendant's motion to strike the notice of trial and compel discovery was reversed and denied.

The relevant facts considered by the court were that the defendant-insurer timely and properly mailed notices regarding independent medical examinations (IMEs) and examinations under oath (EUOs) to the plaintiff's assignor, who then failed to appear for these examinations. The main issue decided by the court was whether the defendant had made a prima facie showing of entitlement to summary judgment dismissing the action for first-party no-fault benefits. The court held that the defendant-insurer had indeed made a prima facie showing, as the plaintiff did not specifically deny the assignor's nonappearance or raise a triable issue with respect to the mailing or reasonableness of the underlying notices. Therefore, the court reversed the order of the Civil Court, granted the defendant's motion for summary judgment, and dismissed the complaint.

The relevant facts considered by the court included that the plaintiff sought payment for $492.84 of health services rendered to an assignor pursuant to New York's No-Fault Law. The defendant, State Farm Mutual Automobile Insurance Company, moved to dismiss the action, contending that the plaintiff violated a policy condition for verification of the claim and failed to provide additional verification as requested. The main issues decided were whether the plaintiff's failure to respond to the defendant's Examination Under Oath (EUO) and verification requests justified dismissal of the action, and whether the EUO request for documents and information was outside the scope of permissible information. The court held that defendant was justified in seeking EUOs and further verification of plaintiff's claims, and that plaintiff's failure to respond to defendant's timely notifications was fatal to its causes of action. The court also held that the defendant's request for the production of documents and information before the EUO was troubling, but it was the plaintiff's reaction to the request that vitiates its causes of action. Ultimately, the court granted the defendant's motion to dismiss the plaintiff's complaint.

The relevant facts considered by the court included a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company had scheduled independent medical examinations (IMEs) for the provider's assignor, but the assignor failed to appear. The insurance company submitted evidence that the IME scheduling letters had been timely mailed, as well as affirmations from its examining physicians stating that the assignor had failed to appear for the scheduled IMEs. The main issue decided was whether the insurance company had established its prima facie entitlement to judgment as a matter of law. The holding of the court was that the insurance company had indeed established its prima facie entitlement to judgment as a matter of law, and therefore the court reversed the denial of the insurance company's motion for summary judgment and granted the motion, dismissing the complaint.

The relevant facts considered by the court in this case were that Midtown Medical Associates, P.C. was seeking to recover first-party no-fault benefits that had been assigned to them by Simeon Johnson. Clarendon National Insurance Co. appealed from the denial of their motion for summary judgment dismissing the complaint on the grounds of lack of medical necessity for the services provided. The main issue decided by the court was whether the affirmed peer review report submitted by Clarendon National Insurance Co. had clearly established a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the services at issue. The court held that as the peer review report failed to clearly establish a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the services at issue, the denial of Clarendon National Insurance Co.'s motion for summary judgment was proper. Therefore, the order denying the motion for summary judgment was affirmed.

The main issue in this case was whether the plaintiff's assignor had failed to appear at scheduled independent medical examinations (IMEs). The defendant moved for summary judgment dismissing the complaint, and the plaintiff cross-moved for summary judgment. The Civil Court found that both parties had established their prima facie cases, and that the only issue for trial was whether the assignor had failed to appear at IMEs. The defendant appealed the order denying its motion for summary judgment, and in support of its motion, submitted affidavits from its examining chiropractors stating that the assignor had failed to appear for the scheduled IMEs. In opposition, the plaintiff failed to raise a triable issue of fact. As a result, the court granted the defendant's motion for summary judgment dismissing the complaint.