No-Fault Case Law

The relevant facts of the case involved a provider seeking to recover assigned first-party no-fault benefits. The provider moved for summary judgment, but the insurance company opposed the motion, arguing that it had timely denied the claims based on the assignor's eligibility for workers' compensation benefits. The main issue decided was whether the provider had complied with the court's order to make a proper application to the Workers' Compensation Board, pursuant to a previous court order. The holding of the case was that the provider had failed to demonstrate that a proper application for workers' compensation benefits had been made within the time provisions set forth in the court's order, and thus, the denial of summary judgment and the granting of the insurance company's cross motion for summary judgment were affirmed.

The court considered a case in which Alfa Medical Supplies, as the assignee of Teresa D. Cortez, appealed from an order dismissing the complaint against Geico General Insurance Company. The main issue was whether defendant had timely denied plaintiff's claims for first-party no-fault benefits. The court affirmed the judgment, holding that the affidavit of defendant's claim representative was sufficient to establish that the claims had been timely denied, and since this was the sole issue raised on appeal, the judgment was affirmed.

The court considered the fact that the plaintiff had filed a breach of contract action in 1998 to recover no-fault benefits for medical treatments she had received as a result of a motor vehicle accident, and that the case was marked off the calendar in 1999. Plaintiff attempted to restore the case to the calendar in 2010, which was denied by the defendant. The main issue decided was whether the plaintiff's motion to restore the case to the calendar should have been denied and whether the defendant's cross motion to dismiss the complaint should have been granted. The holding was that plaintiff's motion to restore the case to the trial calendar was denied, and the defendant's cross motion to dismiss the complaint was also denied. Additionally, it was determined that the defendant's cross motion to dismiss the complaint invoked CPLR 3404, however, as CPLR 3404 applies solely to cases in the Supreme or County Courts, the Civil Court properly denied defendant's CPLR 3404 cross motion to dismiss.

The relevant facts considered by the court were that W.H.O. Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits, but their claim was partially denied by AIG Auto Insurance on the grounds that the unpaid portion exceeded the amount permitted by the workers' compensation fee schedule. The main issue decided was whether AIG's denial of claim forms and explanation of benefit forms were sufficient to apprise the plaintiff of the reasons for the denial. The court held that the denial forms were indeed sufficient, and affirmed the order granting AIG's motion for summary judgment and dismissing the complaint by W.H.O. Acupuncture, P.C. The judgment was subsequently entered, and the court deemed the appeal to have been taken from that judgment.

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.