No-Fault Case Law

The main issue in this case was whether the insurance company was liable to pay first-party no-fault benefits to the plaintiff, a healthcare provider, after the plaintiff failed to appear for two scheduled examinations under oath (EUOs). The defendant argued that the plaintiff's claims should be denied due to their failure to attend the EUOs, and moved for summary judgment. The Civil Court denied the defendant's motion and granted the plaintiff's cross motion for summary judgment, finding that the defendant failed to prove the timely mailing of the denial of claim forms and the EUO scheduling letters. The Appellate Term, however, reversed this decision, ruling that the defendant had indeed established the timely mailing of the EUO scheduling letters, and that the appearance of the plaintiff at an EUO is a condition precedent to the insurer's liability on the policy. Therefore, the court held that the defendant's motion for summary judgment dismissing the complaint should have been granted, and the plaintiff's cross motion for summary judgment should have been denied.

The main issue in this case was whether the defendant had established a lack of medical necessity for the supplies provided to the plaintiff, who was seeking to recover assigned first-party no-fault benefits. The court considered the timely denial of the claim by the defendant on the grounds of lack of medical necessity, as well as an affirmed peer review report. The court held that the defendant had established its prima facie entitlement to summary judgment by providing evidence of the timely denial and the peer review report. In opposition to the motion, the plaintiff failed to submit an affirmation from a doctor rebutting the conclusions in the peer review report, and also failed to demonstrate a need for additional documents. Ultimately, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The case involves a dispute over first-party no-fault benefits in the amount of $25,000, with an insurance company seeking summary judgment to dismiss the complaint on the grounds that the injuries of the plaintiff's assignor were preexisting and unrelated to the subject accident. The plaintiff, an orthopedic surgeon, performed medical procedures on the assignor and submitted a claim for reimbursement, which was denied based on an independent peer review indicating that the injuries were unrelated to the accident. The defendant submitted medical evidence to support their motion for summary judgment, but the court found that the plaintiff's opposition, including an affidavit from the surgeon who performed the procedure, raised a genuine issue of fact that needed to be resolved at trial. Therefore, the court affirmed the order denying the defendant's motion for summary judgment.

The main issue decided in this case was whether the plaintiff's motion to vacate a prior order which had granted on default the defendant's motion to dismiss the complaint for failure to prosecute should be denied. The court considered the fact that the plaintiff had commenced the action in July 2002 to recover assigned first-party no-fault benefits, and issue was joined in September 2002. However, there was no further activity in relation to the litigation until March 2007, when the defendant served a 90-day demand pursuant to CPLR 3216 (b) and the plaintiff did not respond. The court held that the order denying the plaintiff's motion to vacate the order dismissing the complaint should be affirmed, as there was no proof that a notice of change of attorney form was executed in 2003 and filed with the Civil Court at any time prior to the defendant's service of the 90-day demand in March 2007. Therefore, proper service of the demand and of the subsequent motion to dismiss on the plaintiff's former counsel was upheld.

The court considered the plaintiff's motion for summary judgment and the defendant's cross motion to compel the plaintiff to provide discovery and produce its owner for an examination before trial. The main issues decided were whether the plaintiff was obligated to produce certain information in response to the defendant's supplemental demand for discovery and inspection and whether the plaintiff's motion for summary judgment was premature pending the completion of discovery. The holding of the court was that the defendant's cross motion to compel the plaintiff to respond to outstanding discovery demands was granted to the extent of compelling the plaintiff to provide the information sought in certain items of the defendant's supplemental demand for discovery and inspection within 60 days. Additionally, the court found that the plaintiff's motion for summary judgment was premature pending the completion of discovery.

The court found in favor of the plaintiff, Giugliano, DC, P.C. in this matter wherein plaintiff was seeking to recover first party no-fault benefits from defendant, Merchants Mutual Ins. Co. Plaintiff submitted bills for medical procedures pursuant to the New York Workers' Compensation Medical Fee Schedule, however, defendant disputed the billing practices used by the plaintiff. The main issue decided by the court was whether the plaintiff was entitled to recover for the claims submitted based on the fee schedule. The court found that plaintiff proved its prima facie case and the procedures were properly billed pursuant to the fee schedule, which is why it granted judgment in favor of the plaintiff in the amount of $2,980.58 plus costs, disbursements, statutory interest, and statutory attorney's fees.

The court considered a motion for summary judgment in a case brought by Axis Chiropractic, PLLC as assignee of Ricargo Herrera against GEICO General Insurance Company to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff had made a prima facie showing of entitlement to summary judgment, with the court ultimately holding that the plaintiff failed to do so. The court found that the affidavit submitted in support of the motion for summary judgment did not demonstrate personal knowledge of the plaintiff's business practices and procedures, therefore rendering it legally insufficient. As a result, the court affirmed the denial of the plaintiff's motion for summary judgment. No other issues were considered by the court in this case.

The main issue in the case of Points of Health Acupuncture, P.C. v Lancer Insurance Company was whether the defendant had established the timely mailing of denial of claim forms and examination under oath (EUO) scheduling letters, as well as the plaintiff's failure to appear for scheduled EUOs. The court considered that the defendant had established the timely mailing of the EUO scheduling letters with respect to certain claims, and thus was entitled to partial summary judgment dismissing these claims. However, the court found that the defendant had failed to establish the timely mailing of verification requests with respect to other claims, thus precluding the defendant from raising most defenses for these claims. The court also found that plaintiff's cross motion for summary judgment was premature, and that the defendant was entitled to compel the plaintiff to respond to discovery requests. Therefore, the court reversed the order, granted partial summary judgment to the defendant, denied the plaintiff's cross motion for summary judgment, and remitted the matter to the Civil Court for further proceedings on the remaining claims.

The relevant facts of the case were that Yklik, Inc. was seeking to recover assigned first-party no-fault benefits from GEICO Ins. Co. The main issue decided was whether GEICO had timely denied the claims at issue on the ground of lack of medical necessity. The holding of the court was that defendant established that it had timely denied the claims at issue on the ground of lack of medical necessity, and the peer review reports submitted in support of defendant's cross motion for summary judgment set forth a factual basis and medical rationale for the determinations that there was a lack of medical necessity for the supplies furnished. Plaintiff failed to raise a triable issue of fact, and the court reversed the order, denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment dismissing the complaint.

The court considered whether the insurance company, the defendant, had timely denied the provider's claims based on the failure of the provider's assignor to appear for an examination under oath (EUO). The main issue was whether the defendant had demonstrated that its initial and follow-up requests for verification were timely and whether the assignor had failed to appear for the EUOs. The holding of the court was that the defendant failed to establish that the EUO scheduling letters were timely mailed, and therefore, failed to demonstrate that the 30-day claim determination period was tolled. As a result, the defendant failed to establish that its denial of claim forms were timely, and thus, was not precluded from raising as a defense the failure of plaintiff's assignor to appear for an EUO. Therefore, the judgment in favor of the plaintiff was affirmed.