No-Fault Case Law

The relevant facts of the case involved a dispute between Tri-Mount Acupuncture, P.C., as an assignee of Jerry Savage, and NY Central Mutual Fire Insurance Company regarding first-party no-fault benefits. The main issue decided by the court was whether the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The holding of the case was that the defendant, NY Central Mutual Fire Insurance Company, had established its prima facie entitlement to judgment as a matter of law by submitting evidence demonstrating that the plaintiff's assignor had failed to appear for the scheduled IMEs. As a result, the court reversed the judgment, vacated the initial order, denied the plaintiff's motion for summary judgment, and granted the defendant's cross motion for summary judgment dismissing the complaint. The decision was made on March 2, 2011.

The case involved an action by plaintiffs to recover assigned first-party no-fault benefits for medical services, and an appeal from an order of the Supreme Court denying the plaintiffs' motion for summary judgment. The plaintiffs submitted billing forms, affidavits from their third-party biller, certified mail receipts, and a signed return-receipt card demonstrating that they had mailed the necessary billing documents to the defendant, and that payment of no-fault benefits was overdue. The defendant failed to raise a triable issue of fact in opposition to the plaintiffs' motion, and the defendant's verification requests were deemed insufficient. The court held that the plaintiffs had established their prima facie entitlement to judgment as a matter of law, and reversed the order denying the motion for summary judgment.

The relevant facts considered by the court were an action to recover no-fault medical payments under an insurance contract. The plaintiff made a prima facie showing that it was entitled to recover the payments by submitting evidence that the prescribed statutory billing form had been mailed and received by the defendant and that the defendant had failed to either pay or deny the claim within the requisite 30-day period. The main issue decided was whether the defendant timely denied the plaintiff's claim, and the defendant was found to have failed to establish timely denial of the claim. The holding of the court was that the plaintiff's motion for summary judgment on the complaint was granted, and the defendant's cross motion for summary judgment was denied. The court held that the defendant failed to establish timely denial of the claim, which resulted in preclusion of the defense.

The main issue in this case was whether the responsibility for the payment of first-party benefits should be submitted to arbitration. The defendant argued that its denial of benefits raised an issue of coverage rather than payment, but the court found that any controversy between insurers involving the responsibility or obligation to pay first-party benefits is not considered a coverage question and must be submitted to mandatory arbitration. The court held that the defendant was responsible for the payment of the no-fault benefits for the health services provided by the plaintiff, irrespective of any issues of priority or source of payment. Therefore, the order of the Appellate Term of the Supreme Court in the First Judicial Department affirming the order of the Civil Court of the City of New York, Bronx County, which found that the issue of which insurer is the primary insurer must be submitted to arbitration, was unanimously affirmed with costs.

The main issue in this case was whether the injuries sustained by the plaintiff's assignor arose from an insured incident, and therefore whether the defendant was obligated to cover the no-fault benefits. Plaintiff moved for summary judgment, which was opposed by the defendant, who cross-moved for summary judgment dismissing the complaint. The court found that defendant's proof, consisting of an affidavit from a special investigator and a police accident report, did not establish as a matter of law that the injuries did not arise from an insured incident. Therefore, the court denied both plaintiff's motion and defendant's cross motion, concluding that triable issues of fact existed. As a result, the order was affirmed, without costs.

The court considered that the provider had failed to appear for scheduled examinations under oath (EUOs) and had not provided requested additional verification. The main issue decided was whether the EUO scheduling letters were adequate and whether the plaintiff had failed to appear at the scheduled EUOs. The court held that the EUO scheduling letters were timely, and the plaintiff had failed to appear at the scheduled EUOs. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted. The court also determined that there was no requirement for the EUO scheduling letters to conspicuously highlight the time and place of the EUO, as suggested by the Civil Court.

The court considered a case in which a provider sought to recover assigned first-party no-fault benefits from an insurance company and a default judgment was entered against the insurance company. The insurance company sought to vacate the default judgment, stating that a clerical error had caused the late service of the answer. The main issue was whether the insurance company's reason for the default was reasonable and whether they demonstrated a meritorious defense. The holding was that the insurance company did not provide a reasonable excuse for their default, as the purported document served as an answer listed the wrong assignor and did not properly address the complaint. The court affirmed the denial of the insurance company's motion to vacate the default judgment, as there was no reasonable excuse for the default and therefore, it was unnecessary to consider if a meritorious defense was demonstrated.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which denied the defendant's motion for summary judgment dismissing the complaint and granted the plaintiff's cross motion for summary judgment. The main issue decided was whether the supplies provided by the plaintiff were medically necessary, as the defendant argued that they were not. The court held that the defendant's motion for summary judgment should be granted and the plaintiff's cross motion for summary judgment should be denied, as the defendant had submitted affirmed peer review reports from its doctor and sworn peer review reports from its chiropractor, which established a factual basis and medical rationale for the conclusion that there was no medical necessity for the supplies. The plaintiff failed to raise a triable issue of fact in opposition to the defendant's motion as it did not proffer an affidavit from a health-care practitioner that meaningfully referred to or rebutted the conclusions set forth in the peer review reports. Therefore, the decision of the lower court was reversed.

The main issue in this case was whether the medical supplies at issue were medically necessary. The court considered the motion for summary judgment by the plaintiff and the cross motion for summary judgment by the defendant. The defendant submitted peer review reports in support of their motion that stated there was a lack of medical necessity for the supplies. However, the plaintiff's submission of an affirmation of its doctor demonstrated the existence of a question of fact as to medical necessity. Therefore, the court held that there was a triable issue of fact as to the medical necessity of the supplies in question, and the defendant's cross motion for summary judgment was properly denied. The holding was that the sole issue to be determined at trial was the medical necessity of the medical supplies at issue.

The case involves a dispute between ARCO Medical NY, P.C. and Janaa Physical Therapy, P.C. as assignees of Jermaine Rouse, and New York Central Mutual Fire Insurance Company. The providers were seeking to recover first-party no-fault benefits, while the insurance company sought to dismiss the complaint based on the assignor's failure to attend independent medical examinations (IMEs) scheduled by Crossland Medical Services, P.C. The main issue was whether the insurance company had established the mailing of the IME scheduling letters. The court held that the insurance company had failed to establish the mailing of the IME scheduling letters in accordance with Crossland's standard office practices and procedures, and therefore the insurance company's motion for summary judgment was denied. However, the providers did not establish their prima facie case and were not entitled to summary judgment on their cross motion. Therefore, the court modified the order to deny the providers' cross motion for summary judgment.