No-Fault Case Law

The court considered a dispute between Radiology Today, P.C. and GEICO General Insurance Company regarding the recovery of assigned first-party no-fault benefits, with GEICO seeking discovery of documents and information related to the propriety of Radiology's incorporation and operation. GEICO alleged that Radiology's incorporation and operation violated state licensing laws under the precedent established in State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313 (2005). The main issue was whether Radiology's fraud defenses should be waived due to GEICO's failure to plead a defense based on fraud and whether the discovery demands were overbroad. The court decided that the discovery order was proper as GEICO's motion papers demonstrated the potentially meritorious nature of a Mallela-based defense. Since Radiology failed to timely challenge the discovery demands, the judgment dismissing the complaint was affirmed. The court did not address any other issues.

The case involved Astoria Quality Medical Supply as the plaintiff, seeking to recover assigned first-party no-fault benefits for medical supplies furnished to its assignors who were allegedly injured in a motor vehicle accident. The defendant, State Farm Mutual Automobile Ins. Co., had denied the claim on the grounds that it had not issued an insurance policy to the person who owned the vehicle involved in the accident. The Civil Court initially denied the defendant's motion for summary judgment, stating that triable issues of fact existed. However, the plaintiff later moved for summary judgment and was granted the motion. The Appellate Term, Second Department reversed the judgment, holding that while the defendant's proof did not establish as a matter of law that there was a lack of coverage, it was sufficient to raise a triable issue of fact, and the defendant was not required to describe in detail the steps taken to search its records. Therefore, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion for summary judgment was denied.

The relevant facts considered by the court are the background information of Globe Surgical Supply as a provider of Durable Medical Equipment (DME) and their submission of claims to Allstate Insurance Company for reimbursement. The plaintiffs alleged that Allstate illegally reduced reimbursements in violation of insurance regulations. The court considered counterclaims and affirmative defenses by Allstate, alleging fraudulent conduct on the part of the plaintiffs and seeking dismissal of the plaintiffs' class allegations. The main issue decided was the dismissal of Allstate's counterclaims for fraud, violations of the RICO statute, General Business Law §349, unjust enrichment, and affirmative defenses such as overbilling, lack of coverage, fraud, and improper self-referrals. The court also granted Allstate's application to dismiss the plaintiffs' class allegations due to their failure to move for class certification within the required sixty days. The holding of the case is that the court dismissed all of Allstate's counterclaims and affirmative defenses alleging fraud and overbilling, finding that Allstate failed to assert these defenses within the required statutory time frame. The court also granted Allstate's application to dismiss the plaintiffs' class allegations due to their failure to move for class certification within the required time period.

The court considered the issue of whether an insurer is required to issue a denial within 30 days of an injured party's failure to appear for a post-claim IME. The court concluded that the failure to appear for an IME is a violation of a condition precedent to the insurance policy, rather than a policy exclusion, making a denial on this ground not subject to the preclusion rule. The main issue decided in the case was whether the insurer's late denials, due to a failure to appear for an IME, were fatal, and whether an IME no show is a precludable defense. The holding of the case was that the claimant's failure to comply with a condition precedent to coverage voids the contract ab initio, and the defendant is not obligated to pay the claim, regardless of whether it issued denials beyond the 30-day period. The court ultimately dismissed the case with prejudice.

The court considered a dispute between Alev Medical Supply, Inc., as the assignee of Javon Battey, and Progressive Northern Insurance Company over the recovery of first-party no-fault benefits. After participating in a mandatory arbitration proceeding, the arbitrator found in favor of Alev Medical Supply, Inc. The insurance company then served and filed a demand for a trial de novo, which the plaintiff sought to strike. The plaintiff argued that the insurance company's attempt to establish its defense of lack of medical necessity through non-evidentiary submissions of counsel and failure to produce its doctor to testify amounted to a default, and therefore, the insurance company was not entitled to demand a trial de novo. The District Court denied the plaintiff's motion to strike the demand, and the Appellate Term affirmed the decision, citing a similar case as precedent. Therefore, the holding of the case was that the insurance company was entitled to demand a trial de novo despite its actions at the arbitration hearing.

The main issues decided in this case were whether a provider could recover assigned first-party no-fault benefits, and whether an insurance company had a reasonable basis for denying a claim based on the nonappearance of the claimant at two scheduled examinations under oath. The court considered the affidavits submitted by the insurance company's no-fault examiner, mailroom supervisor, and investigator as evidence that the EUO notices had been sent in accordance with standard office practices, and that the claimant had failed to appear for the scheduled examinations. The court held that the insurance company had established a reasonable basis for the EUO request and that the denial of claim forms had been timely mailed, and therefore reversed the previous order, granting the insurance company's cross motion for summary judgment dismissing the complaint and denying the provider's motion for summary judgment.

The court considered the defendant's motion for summary judgment dismissing the complaint on the grounds that the plaintiff's assignor had failed to appear for an independent medical examination (IME), which was a condition precedent to coverage. The defendant submitted an affidavit showing that the IME notices had been sent to the plaintiff's assignor and that the assignor had failed to appear for the duly scheduled IMEs. Additionally, the denial of claim forms were timely mailed in accordance with the defendant's standard office practices and procedures. The main issue decided was whether the plaintiff's assignor's failure to appear for the IMEs constituted a breach of the insurance policy's conditions. The holding of the court was that the appearance of the assignor at an IME was a condition precedent to the insurer's liability on the policy, and therefore the defendant's motion for summary judgment dismissing the complaint was granted.

The main issue in the case was whether the plaintiff had properly served the defendant with a summons and complaint in a no-fault benefits action. The defendant argued that process had not been properly served because they had not signed and returned the acknowledgment of receipt of the summons and complaint within 30 days. The court considered the fact that the plaintiff had attempted to serve the defendant via mail, but the defendant had not signed and returned the acknowledgment of receipt. As a result, the court held that service of process was not effectuated pursuant to CPLR 312-a, and no personal jurisdiction was acquired. Therefore, the court reversed the lower court's decision and granted the defendant's motion to dismiss the complaint.

The main issue in this legal case was whether the defendant insurance company was entitled to summary judgment based on the assignors' failure to appear at scheduled examinations under oath (EUOs) in a no-fault benefits case. The court considered the fact that the insurance company denied all of the claims at issue on the grounds that the assignors had failed to attend the scheduled EUOs. The court held that in order for the insurance company to make a prima facie showing for entitlement to summary judgment, they had to demonstrate that their initial and follow-up requests for verification were timely mailed, and establish, by an affidavit of one with personal knowledge, that the assignors failed to appear for the EUOs. The court found that the defendant failed to establish a prima facie showing and therefore, the Civil Court properly denied the defendant's cross motion for summary judgment. Consequently, the order was affirmed insofar as appealed from.

The relevant facts considered by the court were that a chiropractic practice was seeking to recover first-party no-fault benefits for services rendered to an assignor who was referred to the practice by a non-party practitioner. The insurance company moved for summary judgment dismissing the complaint, claiming that the referral violated Public Health Law § 238-a prohibiting referrals where the referring practitioner has a financial relationship with the healthcare provider. The main issue decided by the court was whether there was a "financial relationship" between the chiropractic practice and the referring practitioner, as defined by section 238(3) of the Public Health Law. The court determined that there was no evidence to establish a "compensation arrangement" or any payments for the rental or lease of office space between the parties. The holding of the case was that the evidence submitted by the insurance company failed to establish a "financial relationship" between the chiropractic practice and the referring practitioner as required by the Public Health Law. Therefore, the court reversed the order granting the insurance company's motion for summary judgment, denied the motion, and reinstated the complaint.