No-Fault Case Law

The court considered an appeal from an order of the Civil Court that granted the defendant's motion for summary judgment dismissing the complaint in an action to recover assigned first-party no-fault benefits. The defendant had established that it had timely denied the claim on the ground of lack of medical necessity and had submitted an affirmed peer review report setting forth a factual basis and medical rationale for the conclusion that the medical services at issue were not medically necessary. The plaintiff did not dispute that the defendant had established lack of medical necessity and did not rebut the defendant's showing that the services at issue were not medically necessary. The main issue decided was whether the defendant's motion for summary judgment was properly granted, and the holding of the court was that the order was affirmed without costs as the plaintiff's remaining contentions lacked merit.

The relevant facts considered by the court were that the plaintiff, a psychologist, had filed a commercial claims action to recover assigned first-party no-fault benefits from the defendant insurance company, Allstate. Allstate failed to appear or answer, resulting in a default judgment against them in 2004. In 2008, Allstate moved to vacate the default judgment, arguing that the small claims part of the Civil Court of the City of New York did not have subject matter jurisdiction over actions brought by an assignee, and that its motion to vacate the default judgment should be granted pursuant to CPLR 317 or 5015. The main issue decided by the court was whether Allstate's motion to vacate the default judgment should be granted, and the holding of the court was that the order denying Allstate's motion to vacate the default judgment was affirmed without costs. The court's decision was based on the reasons stated in a related case, Dr. Robert E. Stoessel, Psychologist, P.C. v Allstate Ins. Co. (___ Misc 3d ___, 2010 NY Slip Op ______ [Appeal No. 2009-576 Q C], decided herewith).

The case involves Allstate Insurance Company appealing a lower court's decision to deny their motion to vacate a default judgment in favor of Dr. Robert E. Stoessel, Psychologist, P.C. The lawsuit revolved around Stoessel suing for assigned first-party no-fault benefits in the sum of $880.52, which Allstate failed to appear or answer to. They argued that small claims court does not have jurisdiction for actions brought by an assignee. However, the appellate court ruled that the action was properly commenced in the Commercial Claims Part by the plaintiff, and that there was proof that the defendant had been served with the notice of claim. Therefore, the motion to vacate the default judgment was denied, and the order was affirmed without costs.

The main issue in this case was whether an insurer could obtain documentary material relating to a potential Mallela defense in a demand for an examination under oath (EUO). The court considered the demand for an EUO that required the production of documents evidencing ownership and financial information of the medical provider, Dynamic Medical Imaging, P.C. The court found that the insurer's demand for written documentation for a Mallela defense through an EUO was improper and not subject to court review. The holding of the court was that the demand for an EUO was improper, and therefore, the insurer's motion for summary judgment was denied. Additionally, the court noted that the defendant had alleged a Mallela defense in their answer and was not prevented from asserting or proving the defense or obtaining proper discovery in regards to the defense.

The court considered the defendant's motion to vacate a default judgment and underlying order in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant had a reasonable excuse for its default and a meritorious defense to the action in order to vacate the judgment and underlying order. The holding of the court was that the defendant established a reasonable excuse for its failure to oppose the plaintiff's motion for summary judgment and also established an arguably meritorious defense to the action. Therefore, the order to vacate the judgment and underlying order was affirmed.

The court considered a provider's action to recover assigned first-party no-fault benefits, with the defendant arguing that the equipment provided was not medically necessary. The Civil Court granted the defendant's motion for summary judgment dismissing the complaint. The main issue decided was whether the defendant had timely mailed its denial of claim form, and the court found that the affidavit submitted by the defendant failed to establish that its standard office practices and procedures were designed to ensure timely mailing. As a result, the defendant failed to demonstrate that its defense of lack of medical necessity was not precluded. The holding of the case was that the order granting the defendant's motion for summary judgment was reversed and the defendant's motion was denied.

The relevant facts considered by the court in this case include a provider's attempt to recover assigned first-party no-fault benefits and the subsequent vacating of a judgment in the provider's favor, leading to a motion for restitution of amounts paid to the provider. The main issue decided was whether the Civil Court properly ordered the provider to return monies paid by the insurance company and to pay half the cost of the insurance company's expert witness at trial. The holding of the court was that the Civil Court did indeed properly exercise its discretion in ordering the provider to return the monies and also properly directed the provider to move to restore the matter to the trial calendar. The court dismissed the appeal from the portion of the order directing the provider to pay half the cost of the insurance company's expert witness, as it was not sought in the insurance company's motion papers.

The relevant facts of the case include a provider, D & R Medical Supply, Inc., seeking to recover assigned first-party no-fault benefits from Safeco Ins. Co. The Civil Court granted the provider's motion for summary judgment, which was then appealed by the insurance company. The main issue at hand was whether the affidavit submitted by the provider's billing manager in support of their motion for summary judgment was sufficient to establish that the documents annexed to the moving papers were admissible pursuant to CPLR 4518. The appellate court held that the affidavit was insufficient in establishing the admissibility of the documents, and therefore reversed the order and denied the provider's motion for summary judgment.

The court considered the petition of All For Happy Smiles Dental, P.C. to vacate a master arbitrator's award, which had upheld the denial of its claim for reimbursement of assigned first-party no-fault benefits. The main issue decided was whether the denial of the claim for reimbursement was upheld by the master arbitrator. The holding of the case was that the order denying the petition to vacate the master arbitrator's award was affirmed without costs, as the facts in this case were the same as those in other similar cases where the denial of the claims was upheld.

The court considered the claim by Raz Acupuncture, P.C. to recover assigned first-party no-fault benefits. AIG Indemnity Insurance Company moved for summary judgment to dismiss the complaint and denied plaintiff's cross motion for summary judgment. The main issue was whether Raz Acupuncture, P.C. was entitled to reimbursement for acupuncture services rendered and the amount of payment it should receive. The court held that the defendant's denial of claim forms were timely mailed and dismissed plaintiff's complaint with respect to the claims. However, the court also held that defendant did not provide sufficient evidence to dismiss plaintiff's claim for the initial acupuncture visit, and therefore denied part of the motion for summary judgment. The court affirmed the modified order, denying summary judgment for the claim of $139.34 and otherwise dismissing the complaint.