No-Fault Case Law

The court considered the appeal of W.H.O. Acupuncture, P.C. as Assignee of Charles Rodriguez, who was seeking to recover first-party no-fault benefits from GEICO General Insurance Company. The main issue decided was whether there was a triable issue of fact as to whether GEICO denied any of the claims at issue, and the court ultimately found that the record did not demonstrate the existence of such an issue. As a result, the court affirmed the judgment of the Civil Court granting GEICO's cross motion for summary judgment, and dismissed the complaint. Therefore, the holding of the case was in favor of GEICO, and the judgment was affirmed.

In the case BLR Chiropractic, P.C. v American Tr. Ins. Co., the plaintiff, a provider seeking to recover first-party no-fault benefits, moved for summary judgment, while the defendant cross-moved for summary judgment dismissing the complaint. The defendant had timely denied the plaintiff's claim on the ground of lack of medical necessity and submitted evidence to support their decision, including a peer review report and affidavit executed by the chiropractor who performed the review. The court found that the evidence submitted by the defendant established a prima facie case of lack of medical necessity for the services at issue, shifting the burden to the plaintiff to rebut the defendant's showing, which they failed to do. As a result, the court reversed the order denying the defendant's cross motion and granted summary judgment dismissing the complaint.

The relevant facts the court considered involved BR Clinton Chiropractic, P.C. as the assignee of an individual, Doreen Polcano, seeking to recover assigned first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue decided was whether defendant was entitled to summary judgment dismissing the complaint and granting plaintiff's cross motion for summary judgment. The court held that the branches of defendant's motion seeking summary judgment dismissing the first, second, fourth and fifth causes of action should be granted, and plaintiff's cross motion for summary judgment should be denied. Additionally, the court found that the denial of claim form was timely mailed and that plaintiff failed to demonstrate that it was conclusory, vague, or without merit as a matter of law.

The court considered an appeal from an order granting the defendant's motion for summary judgment in a case where a provider sought to recover assigned no-fault benefits. The main issue decided was whether there was a triable issue of fact as to the medical necessity of the supplies at issue. The court held that the judgment was reversed, the order granting the defendant's motion for summary judgment was vacated, and the defendant's motion was denied. The court did not find sufficient evidence to support the defendant's argument of lack of medical necessity, and therefore ruled in favor of the plaintiff.

The court considered an order from the Civil Court of the City of New York, Kings County, which granted the defendant's motion for summary judgment dismissing the complaint as to services rendered to Natalia Agudelo and Maria Salazar. The main issue decided was whether the defendant had timely denied the claims based upon the workers' compensation fee schedule, and the court implicitly found that they had. The holding of the case was that the order, insofar as appealed from, was affirmed, without costs. The court found that the plaintiff's argument, that the defendant failed to demonstrate that it had fully paid the plaintiff for the acupuncture services at issue in accordance with the workers' compensation fee schedule, lacked merit. Additionally, the plaintiff's remaining contention was not considered as it was based upon material that was dehors the record.

The relevant facts considered by the court in this case were that Raz Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits from New South Ins. Co. The court considered the denial of plaintiff's claims on the ground that the unpaid portion exceeded the amount permitted by the workers' compensation fee schedule. The main issue decided by the court was whether defendant had timely denied plaintiff's claims and whether it had fully paid the plaintiff for the services in accordance with the workers' compensation fee schedule. The holding of the case was that the order, insofar as appealed from, was affirmed, as defendant had timely denied plaintiff's claims and had fully paid plaintiff for the services in accordance with the workers' compensation fee schedule.

The court considered whether the defendant, Progressive Ins. Co., was entitled to seek discovery related to certain defenses, including the defense that the plaintiff, Medical Polis, P.C., was ineligible to recover no-fault benefits due to non-compliance with state or local licensing requirements. The main issue decided was whether the defendant could compel disclosure and examination before trial of the plaintiff's owner, Nikolai Lagoduke, based on the defense raised. The court held that the defendant was not precluded from seeking discovery related to the defense, even though it had not asserted the defense in its answer. As a result, the court affirmed the order of the Civil Court that granted the defendant's motion to compel disclosure and to produce the plaintiff's owner for examination before trial, and denied the plaintiff's cross motion for a protective order and summary judgment.

The court considered the fact that the defendant-insurer made a prima facie showing of entitlement to summary judgment dismissing the action for first-party no-fault benefits by establishing that it timely and properly mailed the notices for independent medical examinations (IMEs) to plaintiff's assignor, and that the assignor failed to appear. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint, and the court held that the defendant-insurer was entitled to summary judgment and the complaint was dismissed. The court found that the plaintiff did not specifically deny the assignor's nonappearance or otherwise raise a triable issue with respect to the IMEs, and therefore the defendant's motion for summary judgment was granted.

The court considered the requirements for verification requests for examinations under oath (EUOs) as contained in 11 NYCRR §§65-3.5 and 3.6, which do not apply to EUOs scheduled prior to an insurance company's receipt of claim forms. The main issue decided in the case was whether or not the defendant insurance company, Hartford Insurance Co., properly denied the claim based on the assignor's failure to appear at two EUOs. The court held that the insurance company's consent to an adjournment of the initial EUO vitiated its right to count the assignor's failure to appear as a no-show. Furthermore, once the defendant received the claim, it was required to adhere to statutory and regulatory scheme of verification for the processing of no-fault claims, which requires sending a follow-up request for an EUO pursuant to 11 NYCRR §65-3.6(b), once the assignor failed to appear for the scheduled EUO. The court denied the defendant's motion for summary judgment, and the case is to proceed to trial.

The court considered the fact that the order which had granted plaintiff's motion for summary judgment was ruled on default, and, as a result, defendant's opposing papers as well as its cross motion for summary judgment dismissing the complaint were not considered as they were declared untimely due to a briefing schedule set by the Civil Court. Defendant appealed from the denial of its motion to vacate the default order and requested a new determination of plaintiff's motion for summary judgment and defendant's cross motion for summary judgment. The issue was whether defendant had a reasonable excuse for the default and a meritorious defense to the action. The court held that defendant proffered a reasonable excuse for its failure to submit its papers timely and also set forth a meritorious defense. As a result, the judgment was reversed, the order was vacated, and both plaintiff's motion for summary judgment and defendant's cross motion for summary judgment dismissing the complaint were remitted to the Civil Court for a new determination.