No-Fault Case Law

The main issue in this case was the defendant's motion for summary judgment dismissing the complaint by a provider to recover assigned first-party no-fault benefits. The court considered affidavits from the company retained by the defendant to schedule independent medical examinations, which established that the IME scheduling letters had been timely mailed and that the plaintiff's assignors had failed to appear for the duly scheduled IMEs. The court also considered an affidavit demonstrating that the denial of claim forms had been timely mailed based on the assignors' nonappearance at the IMEs. The holding of the court was that since the appearance of an assignor at a duly scheduled IME is a condition precedent to the insurer's liability on the policy, the defendant's motion for summary judgment dismissing the complaint was properly granted. Therefore, the judgment to dismiss the complaint was affirmed.

The court considered a motion for summary judgment and cross motion for summary judgment in a case involving a provider seeking to recover first-party no-fault benefits. Defendant's peer review reports were found to have a factual basis and medical rationale for determining a lack of medical necessity for the services rendered to plaintiff's assignors. Plaintiff's remaining contentions were found to lack merit. The main issue decided was whether the peer review reports provided a factual basis and medical rationale for determining the lack of medical necessity. The holding of the case was that the judgment denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment was affirmed.

The main issue in this case was whether or not the court should grant an order compelling disclosure and discovery in aid of arbitration from the respondent, Kissena Medical Imaging, P.C. The court was also asked to decide on temporarily staying certain pending arbitrations commenced by Kissena Medical Imaging and enjoining it from commencing any further No-Fault arbitration proceedings for reimbursement of benefits. The court considered the over 40 petitioner insurance companies that had commenced the proceeding to stay certain pending and anticipated no-fault arbitrations and all proceedings instituted by the respondent. The holding of the case was that the court granted the petitioner's request for an order compelling disclosure and discovery in aid of arbitration and that the respondent was temporarily enjoined from commencing any further No-Fault arbitration proceedings for reimbursement of benefits.

The court considered an action by Westchester Medical Center to recover no-fault medical payments under a policy of automobile insurance. The plaintiff appealed from an order that denied its motion for summary judgment on the complaint. The main issue decided by the court was whether the plaintiff demonstrated its entitlement to judgment as a matter of law by submitting evidence that the prescribed statutory billing form had been mailed and received by the defendant insurance company, which failed to either pay or deny the claim within the requisite 30-day period. The court held that while the plaintiff had demonstrated its prima facie entitlement to judgment, the defendant had established that it had made a timely request for additional verification and timely denied the claim within 30 days of receipt of the requested information. Therefore, the Supreme Court properly denied the plaintiff's motion for summary judgment on the complaint.

The court considered the case of Concourse Chiropractic, PLLC, suing as the assignee of Odalis Guzman to recover first party no-fault benefits for chiropractic treatment provided to Guzman. State Farm Mutual Insurance Company acknowledges timely receipt of bills for treatment provided to Guzman, but also has concerns about the operation of Concourse and other related practices owned by Mitchell Zeren, D.C. State Farm's investigation raised questions about the ownership and control of these entities. State Farm demanded an Examination Under Oath (EUO) and extensive corporate records from Concourse, as part of its investigation into a Mallela defense, in relation to the license of professionals owning or controlling these businesses. Concourse did not respond to the EUO requests or provide the requested documents, leading State Farm to deny the claims. The court held that State Farm's demand for extensive corporate records as part of the EUO was improper and denied State Farm's motion for summary judgment. The main issues decided in the case were whether an insurer can demand extensive corporate records in relation to a Mallela defense as part of an EUO, and whether the demand for such information was contrary to the no-fault regulations. The court held that State Farm's demand for such extensive corporate records was an abuse of the EUO process and was not in line with the regulations. The court also found that State Farm had already paid the benefits to Concourse after they defaulted in appearing for an EUO, and that State Farm's repeated and repetitive use of the demand for an EUO and Mallela verification was aimed at obtaining an absolute defense to an otherwise indefensible situation. Ultimately, State Farm's motion for summary judgment was denied, and their motion for summary judgment stayed discovery. The holding of the case was that State Farm's demand for extensive corporate records as part of the EUO process was improper, and their motion for summary judgment was denied. Additionally, State Farm's motion for summary judgment stayed discovery, and Concourse's motion to strike State Farm's answer for failing to respond to discovery demands was restored to the motion calendar.

The court considered the facts of a no-fault first-party action which was validly settled, but there was a dispute over the intended amount of the settlement. The plaintiff drafted a proposed settlement agreement, and the defendant made and initialed several handwritten changes to the document. The plaintiff did not object to the changes, nor took any other action in the case for a full six months. The issues decided were whether the defendant's proposed modifications to the agreement were accepted by the plaintiff through their "acquiescent conduct," and whether the judgment at issue could be considered a default judgment. The holding was that the plaintiff, through their acquiescent conduct, accepted and was bound by the stipulation's revised terms, and the judgment at issue was not a default judgment as it was erroneously treated as by the lower court.

The court considered the background of the case, which involved a motor vehicle accident in Brooklyn, New York. The accident involved two vehicles insured by Geico and resulted in multiple claims for injuries. Geico's Special Investigations Unit (SIU) conducted an investigation into the incident, suspecting it may have been a staged accident. The main issue in the case was whether Geico had an objective basis and justification for requesting an Examination Under Oath (EUO) when suspecting a staged accident. The court ultimately held that Geico did not have a factual basis or founded belief in the suspected staged accident and therefore the request for an EUO was improper. The court also noted that Geico failed to establish whether the EUO notices mailed to the plaintiff were delivered or not. Therefore, the court denied Geico's motion for summary judgment.

The relevant facts the court considered were that the plaintiff's insured's motor vehicle was hit by a motor vehicle allegedly owned and operated by the defendants, resulting in the plaintiff paying $2,000 in excess no-fault benefits to their insured. The plaintiff then commenced a subrogation action against the defendants. The main issue decided was whether the defendant, Robert J. Young, should be allowed to open his default and serve and file an answer after appearing at an inquest. The holding of the case was that the District Court should not have entertained Robert J. Young's oral application to open his default and serve and file an answer, as it was required to be supported by proper motion papers. The court reversed the order denying the plaintiff's motion to vacate the order granting the defendant's oral application and granted the plaintiff's motion, denying the defendant's application without prejudice to renewal upon proper motion papers.

The court considered the fact that Westchester Medical Center was seeking to recover assigned first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue was whether plaintiff had demonstrated its entitlement to judgment as a matter of law, and whether defendant's cross motion for summary judgment dismissing the complaint should be granted. The holding of the court was that the District Court properly denied plaintiff's motion for summary judgment, as they had not demonstrated their prima facie entitlement to judgment. However, the court also held that defendant's cross motion for summary judgment dismissing the complaint should have been denied, as they had failed to submit sufficient evidence to demonstrate that the assignor's alleged intoxicated condition was a proximate cause of the accident. Therefore, the order was modified to deny defendant's cross motion for summary judgment dismissing the complaint.

The court recognized that the no-fault provider had established its prima facie entitlement by submitting the claim forms, proving the amount of the loss sustained, and demonstrating that defendant failed to pay or deny the claim within the 30-day period, which was a requirement by law. The appellate term held that the claim forms had been mailed to the defendant within 45 days of the date services were rendered, and the basis for defendant's denials of claim was without merit as a matter of law. The court disagreed with the defendant's contention that the date of the defendant's receipt of the claim form determined whether the submission was untimely, stating it was the date of plaintiff's submission of the claim form that was relevant. Ultimately, the court reversed the order denying plaintiff's motion for summary judgment, granted the motion, and sent the matter back to the Civil Court for a calculation of statutory interest and an assessment of attorney's fees.