No-Fault Case Law

Altercare Acupuncture, P.C. v Utica Mut. Ins. Co. (2011 NY Slip Op 51639(U))

The main issue decided in this case was whether the defendant insurer was entitled to dismissal of the action for payment of no-fault benefits on the grounds of res judicata and collateral estoppel. The court considered the fact that the defendant had brought an action in Supreme Court, Nassau County, seeking declaratory relief, which was granted by default judgment when the plaintiff failed to appear or serve an answer. The court held that the default declaratory judgment had preclusive effect and therefore the plaintiff was barred from relitigating the claim, and granted the defendant's motion to dismiss on the ground of res judicata. The court also considered relevant case law and analysis of applicable law and policies to reach its decision. Ultimately, the court held that the doctrines of res judicata and collateral estoppel are designed to put an end to a matter once it is duly decided, and since the default judgment had not been vacated, it had preclusive effect, and therefore the motion to dismiss was granted.
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Harmonic Physical Therapy, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51597(U))

The court considered the defendant's motion for summary judgment to dismiss the complaint in an action to recover assigned first-party no-fault benefits. The main issue was whether the defendant established prima facie that it mailed notices of independent medical examinations to the assignor and that the assignor failed to appear. The holding of the court was that the defendant's documentary submissions did establish prima facie evidence that the notices were mailed and the assignor failed to attend the exams. In opposition, the plaintiff failed to raise a triable issue regarding the reasonableness of the requests or the assignor's failure to attend the exams, therefore the motion for summary judgment was granted and the complaint was dismissed.
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MSSA Corp. v Redland Ins. Co. (2011 NY Slip Op 51606(U))

The relevant facts the court considered in MSSA Corp. v Redland Ins. Co. were that MSSA Corp. was seeking to recover assigned first-party no-fault benefits from Redland Insurance Company, and Redland had denied the claims based on lack of medical necessity. The main issues decided were whether Redland's denial of claim forms denying the claims at issue on the ground of lack of medical necessity had been timely mailed and whether the peer review report submitted by Redland was sufficient to establish a lack of medical necessity. The holding of the case was that Redland's motion for summary judgment should have been granted, as their denial of claim forms had been timely mailed and the peer review report, along with an affirmation by the physician who performed the peer review, set forth a factual basis and medical rationale for the conclusion that there was no medical necessity for the medical supplies at issue, and plaintiff had failed to proffer an affidavit from a health care practitioner which meaningfully referred to, let alone rebutted, the conclusions set forth in the peer review report.
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Jesa Med. Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 51603(U))

The relevant facts the court considered centered around an action by a provider to recover assigned first-party no-fault benefits. Plaintiff moved for summary judgment, but defendant opposed the motion, arguing that the action was premature and that there was a lack of medical necessity for certain claims. The main issues decided were whether the action was premature and whether there was a lack of medical necessity for the claims. The holding of the court was that defendant had not received requested verification for certain claims, making the action premature, and that defendant had demonstrated a lack of medical necessity for another claim, leading to the granting of defendant's cross motion for summary judgment dismissing the complaint.
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New York Cent. Mut. Ins. Co. v McGee (2011 NY Slip Op 06253)

The case involved an insurance company seeking a declaration that it was not obligated to pay no-fault insurance claims submitted by a licensed physician and professional medical service corporations for services that were not provided. The insurance company alleged that the corporations were fraudulently incorporated and therefore ineligible for the insurance benefits. The main issue decided by the court was whether the action against the corporations should be severed and if the insurance company's motion to dismiss the counterclaims made by the defendants should be granted. The court held that the action against the corporations should not be severed as it involved common factual and legal issues and that granting the insurance company's motion to dismiss the counterclaims was proper, as the defendants failed to demonstrate that they were entitled to reimbursement for medical services under the insurance policies.
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Q-B Jewish Med. Rehabilitation, P.C. v Allstate Ins. Co. (2011 NY Slip Op 51551(U))

The main issues in the case were whether the defendant's motion to strike the action from the trial calendar and compel plaintiff to respond to defendant's discovery demands and produce its owner for an examination before trial should be granted, and whether plaintiff's bank statements, tax returns, and payroll tax filings should be provided to the defendant. The court held that the motion to strike the action from the trial calendar and to compel plaintiff to respond to discovery demands is justified under the circumstances, and that the plaintiff's bank statements, tax returns, and payroll tax filings should be disclosed to the defendant as they are relevant to the case. However, the court also determined that the plaintiff's responses to the remainder of the defendant's interrogatories and notice to produce were already sufficient, so the Civil Court should not have ordered the plaintiff to provide additional responses. The decision was affirmed with modifications.
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Manhattan Med. Imaging, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51541(U))

The main issue in this case was whether the peer review report submitted by the defendant established a lack of medical necessity for the services rendered. The court found that the defendant's showing of a lack of medical necessity was not rebutted by the plaintiff. Additionally, the court found that the defendant's NF-10 denial of claim forms were timely, a finding which the plaintiff did not challenge. Ultimately, the court held that the defendant's cross motion for summary judgment dismissing the complaint should have been granted based on the lack of medical necessity and the timely denial of claim forms. Therefore, the order of the Civil Court was reversed and the defendant's cross motion for summary judgment dismissing the complaint was granted.
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Baldwin Acupuncture, P.C. v Allstate Ins. Co. (2011 NY Slip Op 51536(U))

The court considered the circumstances surrounding a stipulation of settlement entered into by the parties following the entry of a default judgment against the defendant. The main issue was whether the stipulation of settlement should be vacated, and if the default judgment should be vacated as well. The holding of the court was that the stipulation of settlement should not be vacated as neither mutual mistake nor fraudulent inducement had been established. However, the court decided that the default judgment should not be vacated, and instead granted the defendant's motion for an order directing entry of a satisfaction of the judgment. The court emphasized that strict enforcement of a stipulation of settlement is essential to the management of court calendars and the integrity of the litigation process.
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Neomy Med., P.C. v GEICO Ins. Co. (2011 NY Slip Op 51532(U))

The main issues decided in the case were whether the denial of a claim for medical services was timely mailed by the insurance company and whether the medical services provided were determined to be medically necessary. The court considered the affidavit from the insurance company’s representative regarding the mailing procedure, as well as the peer review report which stated that there was a lack of medical necessity for the services at issue. The court held that the insurance company had established its prima facie entitlement to summary judgment by timely mailing the denial of claim form and providing a peer review report supporting the lack of medical necessity for the services. The court reversed the lower court’s decision and granted the insurance company’s cross motion for summary judgment dismissing the complaint.
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Shoreline Healing Acupuncture Group, P.C. v American Tr. Ins. Co. (2011 NY Slip Op 51531(U))

The relevant facts considered by the court in this case were that Shoreline Healing Acupuncture Group, P.C., as an assignee of TANIA STEVENS and LA TEY STEVENS, had moved for summary judgment to recover first-party no-fault benefits. American Transit Insurance Company, the defendant, cross-moved for summary judgment to dismiss the complaint on the grounds that the plaintiff's assignors had failed to comply with a condition precedent to coverage by failing to appear for an independent medical examination (IME). The main issue decided was whether the plaintiff's submission of its bills to the defendant was late and whether the assignors had failed to appear for a scheduled IME. The court held that the appearance of an assignor at an IME is a condition precedent to the insurer's liability on the policy, and as such, the defendant's motion for summary judgment dismissing the complaint should have been granted. Therefore, the court reversed the order, granted summary judgment in favor of the defendant, and limited the issues for trial.
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