No-Fault Case Law

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.

The court considered the fact that a medical care provider was seeking to recover assigned first-party no-fault benefits and had submitted claim forms to the defendant in order to establish its prima facie entitlement to summary judgment. The main issue decided by the court was whether the medical care provider had provided sufficient foundation to establish that the claim forms submitted were admissible under the business records exception to the hearsay rule. The holding of the court was that the medical care provider failed to make the necessary showing that its billing company incorporated its medical records into its own and relied upon them, therefore, its medical records did not meet the test of the business records exception to the hearsay rule. As a result, the claim forms created by the billing company did not fall within the business records exception to the hearsay rule, and plaintiff failed to demonstrate its prima facie entitlement to summary judgment. Therefore, the Civil Court's order was affirmed.

In this case, the plaintiff, Mount Sinai Hospital, sought to recover no-fault medical payments from the defendant, Country Wide Insurance Company, under an insurance contract. The hospital had previously been awarded a judgment by the Supreme Court, which amounted to $25,327.50. The insurance company then moved to modify the judgment because it claimed that the policy limits were nearly exhausted. However, the court held that the insurer's motion to modify the judgment under CPLR 5019(a) was not the appropriate procedural mechanism as it was trying to change substantive matters rather than just correcting an error. Based on this decision, the insurer's motion to modify the judgment was denied and the original judgment of $25,327.50 stood.

The relevant facts of the case involved a provider seeking to recover assigned first-party no-fault benefits for supplies allegedly delivered to its assignor. The main issue decided by the court was whether the affidavit submitted by the plaintiff's "sole shareholder, corporate officer and employee" in support of the motion for summary judgment made out a prima facie case. The court held that the billing records submitted by the plaintiff did not assert that the supplies at issue had been delivered to the assignor, and the affidavit did not specify which method of delivery was used in this case. The court concluded that plaintiff's moving papers failed to demonstrate its prima facie entitlement to summary judgment. The order denying plaintiff's motion for summary judgment was affirmed on the ground that the plaintiff failed to make out a prima facie case.

The court considered the fact that defendant reimbursed the plaintiff for services rendered by a licensed acupuncturist to the plaintiff's assignor. Defendant used the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount that plaintiff was entitled to receive for the services rendered. The main issue decided was whether it was proper for the defendant to use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount owed to the plaintiff. The court held that it was proper for the defendant to use this fee schedule, and as a result, granted the defendant's motion for summary judgment and dismissed the complaint. The judgment was affirmed without costs.

The court considered the issue of whether a demand for a trial de novo could be made by a party who participated in mandatory arbitration, but whose evidence was ruled inadmissible by the arbitrator. The main issue decided was whether the defendant was in default for the purposes of making a demand for a trial de novo. The court held that a party's failure to appear for an arbitration hearing constitutes a default, as does an appearance by counsel who refuses to participate in the hearing. However, where a party's attorney appears at the arbitration, participates in the hearing, and submits evidence that would have tended to rebut the plaintiff's case if admissible, there is no default within the contemplation of the Rules of the Chief Judge. Therefore, the District Court properly denied the plaintiff's motion to strike the defendant's demand for a trial de novo.

The relevant facts in this case involved an action by medical providers to recover first-party no-fault benefits, with the parties participating in mandatory arbitration. The arbitration resulted in a ruling in the plaintiffs' favor, but the defendant then served and filed a demand for a trial de novo. The plaintiffs argued that the defendant's limited participation in the arbitration amounted to a default, barring them from demanding a trial de novo, but the District Court denied the motion. The main issue was whether the defendant's limited participation in the arbitration constituted a default. The holding of the case was that where a party's attorney appears at the arbitration, participates in the hearing, and submits evidence that, if admissible, would have tended to rebut the plaintiff's case, there is no default within the contemplation of the rules, and therefore the District Court properly denied the motion to strike the demand for a trial de novo.