No-Fault Case Law

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which had denied the defendant's motion for summary judgment dismissing the fifth cause of action in a first-party no-fault benefits case. The defendant argued that the services rendered were not medically necessary. The court found that the submission of the affirmation executed by the plaintiff's principal was improper, as it did not comply with CPLR 2106, and that the plaintiff failed to proffer any evidence in admissible form which raised an issue of fact. The court reversed the order and granted the defendant's motion for summary judgment dismissing plaintiff's fifth cause of action. The main issue was whether the defendant's denial of the claim form denying the claim at issue on the ground of lack of medical necessity was timely, and whether the plaintiff's submission of the affirmation executed by its principal was proper. The holding was that the defendant's motion for summary judgment dismissing the fifth cause of action was granted, as the plaintiff failed to proffer any evidence in admissible form which raised an issue of fact.

The court considered an appeal from an order of the Civil Court of the City of New York, in which a judgment was entered awarding the plaintiff the principal sum of $1,156.98 in an action to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant had properly paid for the services at issue at a rate reduced pursuant to the workers' compensation fee schedule and whether there was a lack of medical necessity for the denied services. The court held that the denial of the claim forms were timely mailed in accordance with the defendant's standard office practices and procedures. Additionally, the court determined that it was proper for the defendant to use the workers' compensation fee schedule to determine the amount the plaintiff was entitled to receive for acupuncture services performed by chiropractors. The court also found that there was a lack of medical necessity for the denied services after an independent medical examination took place, and therefore granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered a case in which a provider was seeking recovery of assigned first-party no-fault benefits. Defendant had alleged that it had properly paid for the services at issue at a reduced rate and denied reimbursement for lack of medical necessity based on an independent medical examination. The main issues decided were whether plaintiff was entitled to summary judgment, whether the denial of claim forms were timely mailed, and whether there was sufficient evidence to dismiss plaintiff's claim for the initial acupuncture visit. The holding of the case was that the plaintiff was entitled to summary judgment for the initial acupuncture visit, but not for the remaining claims. Additionally, the court found that the denial of the fourth and fifth causes of action for lack of medical necessity was justified based on the evidence presented.

The main issues in this case were whether the services provided were medically necessary and if the denial of the claim by the insurance company was timely mailed. The court considered the affidavit submitted by the insurance company's claims division employee, which established that the denial of the claim form was timely mailed in accordance with their standard office practices and procedures. The court also considered the affirmed peer review report by the insurance company's doctor, which set forth a factual basis and medical rationale for the opinion that the services provided were not medically necessary. However, the court found that the plaintiff proffered an affidavit in admissible form from its owner, a chiropractor, which referred to the insurance company's peer review report and sufficiently rebutted its conclusions. Therefore, the court held that a triable issue of fact as to medical necessity existed and reversed the judgment, vacated the order granting the plaintiff's motion for summary judgment, and denied the plaintiff's motion for summary judgment.

The relevant facts considered by the court were that the plaintiff had filed a cause of action to recover first-party no-fault benefits pursuant to a policy of insurance. The defendant had denied the claim, and the plaintiff had filed a complaint. The main issue decided by the court was whether the cause of action was filed within the applicable six-year statute of limitations. The holding of the court was that the cause of action was not interposed within the statute of limitations, since it accrued on the date the claim became overdue, not the date of the defendant's untimely denial of the claim. The court reversed the lower court's decision, granted the defendant's motion for summary judgment, and directed the clerk to enter judgment accordingly, dismissing the complaint.

The main issue before the court was whether the SUM arbitrator had exceeded the scope of his authority by not giving preclusive effect to a prior arbitration award involving the same parties and accident. Petitioner was involved in a two-car collision and filed a claim for no-fault benefits, which was ultimately awarded to petitioner. After settling a lawsuit against the other driver, petitioner sought SUM benefits from the insurer, but the insurer denied the claim. The arbitrator issued an award in favor of the insurer denying SUM benefits, and the petitioner commenced this CPLR article 75 proceeding to set aside the SUM arbitration award. The court had to decide if the arbitrator's removal of using the prior no-fault arbitration award in the subsequent dispute was valid. The court held that the arbitrator's rulings in the SUM arbitration were largely unreviewable, concluding that the arbitrator did not violate any public policy, and therefore, the prior award was not to be used in the summation arbitration.

The main issues in the case were whether a provider could recover assigned first-party no-fault benefits when the assignor had failed to appear at duly scheduled examinations under oath (EUOs), and whether the appearance at an EUO was a condition precedent to an insurer's liability on the policy. The court considered the affirmation submitted by the associate of the law firm retained by the defendant, which established that the plaintiff's assignor had failed to appear at the EUOs. The court held that appearance at an EUO is a condition precedent to an insurer's liability on the policy, and since the assignor had failed to appear, the judgment in favor of the plaintiff was reversed, the order granting the plaintiff's motion for summary judgment was vacated, and the plaintiff's motion was denied.

The relevant facts considered by the court were that the defendant moved for summary judgment dismissing the complaint on the grounds that the services rendered were not medically necessary. The plaintiff opposed the motion, but the Civil Court granted the motion, finding that the plaintiff had failed to establish the existence of a triable issue of fact. The main issue decided was whether the defendant had made a prima facie showing of its entitlement to summary judgment dismissing the complaint, and the court held that the defendant had, as they had timely denied the claims on the ground of lack of medical necessity and submitted an affirmed peer review report from its doctor. The holding of the case was that the order granting the defendant's motion for summary judgment dismissing the complaint was affirmed.

The court considered the facts of the case where Richard Amato, a chiropractor, sued to recover first-party no-fault benefits for chiropractic care he provided to Sandra Burrell after she was involved in a motor vehicle accident. State Farm Insurance denied payment for the treatment based on an independent medical examination (IME) performed by Dr. Aordkian, which concluded that Burrell needed no further chiropractic treatment. However, it was found that State Farm failed to obtain verification of the treatment or establish a medical rationale for its determination that the treatment was unnecessary. The court held in favor of the plaintiff, Amato, and ordered judgment in his favor in the amount of $1,920.90, together with interest and other legal fees, as State Farm did not meet the burden of proving that the treatment was unnecessary based on the IME cutoff. The decision held that a timely submitted claim for medical services rendered after the issuance of an IME cutoff is presumed to be medically necessary, and the burden falls on the defendant to prove otherwise.

The court considered whether Westchester Medical Center was entitled to judgment as a matter of law in an action to recover no-fault medical payments under an insurance contract. Specifically, the main issue decided was whether the defendant, Government Employees Insurance Company, properly denied the plaintiff's claim for no-fault benefits based on the alleged intoxication of the plaintiff's assignor at the time of the accident. The court held that the defendant failed to raise a triable issue of fact as to whether the plaintiff's assignor was injured as a result of operating a motor vehicle while in an intoxicated condition. This lack of evidence from the defendant ultimately led to the decision that the plaintiff's motion for summary judgment on the complaint should have been granted.