No-Fault Case Law

The court considered an appeal from a judgment in favor of Jesa Medical Supply, Inc. as an assignee to recover first-party no-fault benefits from American Transit Ins. Co. The main issue decided was whether defendant had timely mailed its request for verification and if plaintiff had provided such verification to defendant prior to commencing the action. The court held that the defendant had demonstrated that it had timely mailed its request for verification and that plaintiff did not show that the verification had been provided to defendant. Consequently, the 30-day period within which defendant was required to pay or deny the claims did not begin to run, making plaintiff's action premature, and therefore the judgment in favor of Jesa Medical Supply, Inc. was reversed.

The court considered the appeal from an order of the Civil Court of the City of New York, Kings County denying defendant's motion for summary judgment dismissing the complaint. The main issue was whether the denial of claim form, which denied the claim at issue on the ground of lack of medical necessity, had been timely mailed and whether defendant had provided sufficient evidence to support its determination that the medical supplies at issue were not medically necessary. The court held that defendant's affidavit, along with the chiropractor/acupuncturist's peer review report, established a factual basis and medical rationale for the determination that there was a lack of medical necessity for the supplies, and that the plaintiff did not rebut this showing. As a result, the court reversed the order and granted the defendant's motion for summary judgment dismissing the complaint.

Facts: This case involves an appeal by the defendant insurance company after an action by a healthcare provider to recover assigned first-party no-fault benefits. The provider moved for summary judgment and the defendant cross-moved for summary judgment to dismiss the complaint. Issues: The main issues were whether the provider failed to submit proof of claim to the insurer within the required 45-day period, whether defendant's claims of excessive fees charged by the provider were sufficient for summary judgment, and whether an independent medical examination found further acupuncture treatment unnecessary, justifying the denial of a portion of plaintiff's claim. Holding: The court ordered that the branch of the defendant's cross-motion seeking summary judgment dismissing the portion of the plaintiff's claim for dates of service from August 29, 2007, to September 6, 2007 is granted. They found that there was no issue of fact about the date that the claim form was mailed, entitling the defendant to summary judgment dismissing the claim for treatment on May 23, 2007 and May 24, 2007. Additionally, the decision explicitly stated that a lower court should be obliged to take notice of the rates set forth in the workers' compensation fee schedule, and that defendant's allegations of excessive fees charged by plaintiff were insufficient to establish the defendant's contention. Therefore, the defendant was not entitled to summary judgment for these claims.

The court considered an appeal from a denial of a motion for summary judgment in a case involving a disputed claim for first-party no-fault benefits. The main issue was whether the defendant insurance company had established prima facie evidence that it had properly notified the policyholder of an independent medical examination (IME) and that the policyholder had failed to attend. The court held that the defendant's submissions had indeed established prima facie that it had mailed the notices of the IMEs and that the policyholder had failed to attend. The court reversed the lower court's decision, granted the motion for summary judgment, and dismissed the complaint. Therefore, the defendant insurance company was not liable to pay the first-party no-fault benefits claimed by the plaintiff medical provider.

The case involved a dispute between Allstate Insurance Company and Alicia A. Jackson in regards to a default judgment entered against her in a negligence case. Allstate claimed that Jackson and Kevin D. Hudson were responsible for injuries sustained by their insured individuals due to a car accident. After a default judgment was entered against Hudson for failure to appear or answer, and against Jackson for failure to appear at trial, Jackson moved to vacate the default judgment against her, asserting that she was not driving the car at the time of the accident. The main issue decided by the court was whether Jackson had a reasonable excuse for her default and whether she had a meritorious defense to the action. The court determined that Jackson failed to offer any evidence to rebut the presumption that Hudson drove the vehicle with her consent, and her assertion that she was not driving the vehicle did not constitute a meritorious defense to the action. Therefore, the court reversed the order and denied Jackson's motion to vacate the default judgment entered against her.

The relevant facts in the case include a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company timely denied the claim on the ground of lack of medical necessity. The main issue decided in this case was whether the insurance company's peer reviewer's report demonstrated a lack of medical necessity for the services at issue, which would shift the burden to the provider to rebut the insurance company's showing. The holding of the court was that the insurance company's peer reviewer's report did set forth a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity, and the provider failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity. Therefore, the court reversed the order denying the insurance company's motion for summary judgment and granted the motion for summary judgment dismissing the complaint.

The relevant facts in this case were that the plaintiffs failed to timely provide defendant with the so-ordered discovery responses, which would preclude them from offering evidence at trial. The main issue decided was whether the plaintiffs had a reasonable excuse for their failure to comply with the so-ordered stipulation and the existence of a meritorious cause of action. The Court held that the conditional so-ordered stipulation becomes absolute upon a party's failure to sufficiently and timely comply and that the plaintiffs failed to demonstrate a reasonable excuse for their failure to timely comply with the stipulation and the existence of a meritorious cause of action. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.

The relevant facts considered in this case were that the defendant had moved to compel the plaintiff to produce two principals for depositions and the plaintiff cross-moved for summary judgment upon seven claims. The issues decided were whether the defendant was entitled to the discovery it sought and whether the defendant was precluded from raising certain defenses. The holding of the case was that the defendant was not entitled to the discovery it sought because the defenses were precluded. The court also determined that the defendant was not precluded from interposing certain defenses with respect to five remaining claims, so the branches of the plaintiff's cross motion seeking summary judgment upon those claims were denied.

The main issues in the case were whether the insurance company, Lancer, was entitled to depositions from two of the plaintiff's principals, Dr. Mayard and Dr. Berardi, and whether Lancer had timely denied the claims at issue. Lancer sought the depositions in order to obtain information regarding the treatment and billing practices of the plaintiff. The court held that Lancer was not entitled to the depositions, as they only sought them for purposes which the court found to be precluded. Additionally, the court held that Lancer failed to prove that it had timely denied the claims at issue, and therefore, was precluded from asserting certain defenses. As a result, Lancer's motion to compel plaintiff to produce the principals for depositions was denied, and plaintiff's cross-motion for summary judgment was granted.

The court considered whether the defendant was entitled to compel the plaintiff to produce two of its principals for depositions and whether the plaintiff was entitled to summary judgment in an action to recover assigned first-party no-fault benefits. The main issues decided were whether the defendant's requests for EUOs were timely mailed, and whether the denial of claims was timely and proper based on plaintiff's failure to comply with a condition precedent to coverage. The court held that the defendant's motion to compel the plaintiff to produce the principals for depositions should have been granted because the information sought was material and necessary to the defense. However, the court also held that the plaintiff's cross motion for summary judgment was denied, as the defendant demonstrated that the plaintiff failed to comply with a condition precedent to coverage. Therefore, the defendant raised a triable issue of fact, and the plaintiff's motion was denied.