No-Fault Case Law

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.

The court considered the circumstances under which a motion for summary judgment was granted on default and the subsequent motion to vacate that order. The main issue was whether the defendant had a reasonable excuse for the default and a meritorious defense to the action. The holding of the case was that the defendant had sufficiently demonstrated a reasonable excuse for the default and a meritorious defense, based on the details provided in their attorney's affirmations and the employee's affidavit. Therefore, the court reversed the previous order, granting the defendant's motion to vacate the prior order and denying the plaintiff's motion for summary judgment.

The main issue in this case was whether the medical equipment provided to plaintiff's assignor was medically necessary, and if the denial of the claim by the defendant was justified. The court considered the evidence provided by both the plaintiff and the defendant, including an affirmed peer review report setting forth the rationale for the doctor's conclusion that the supplies were not medically necessary. The court held that the defendant had proffered sufficient evidence to demonstrate the existence of a triable issue of fact as to medical necessity and that the plaintiff's motion for summary judgment should have been denied. Consequently, the judgment was reversed, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion for summary judgment was denied.

The relevant facts the court considered in this case were that Friendly Physician, P.C. was seeking to recover first-party no-fault benefits, and the defendant, GEICO Ins. Co., had denied the claim. The main issues decided were whether the documents submitted by the plaintiff were admissible and whether the defendant had established that denial of claim forms were timely mailed. The holding of the case was that the affidavit submitted by the plaintiff's billing administrator was sufficient to establish the admissibility of the documents, and the defendant had failed to establish that the denial of claim forms were timely mailed. As a result, the defendant failed to establish its entitlement to summary judgment or the existence of a triable issue, so the judgment in favor of the plaintiff was affirmed.

The court considered the fact that a default judgment had been vacated by the Civil Court, and the defendant had alleged that the default judgment was obtained through the plaintiff's fraud, misrepresentation, or misconduct. The main issue was whether the defendant's default was excusable as the result of law office failure, and if there was a meritorious defense of intrinsic fraud committed by the plaintiff. The holding of the case was that the Civil Court had improvidently exercised its discretion in granting the defendant's motion to vacate the default judgment, and as a result, the defendant's motion to vacate the default judgment was denied, and the judgment was reinstated. The dissenting opinion of Judge Golia argued that the defendant's default was excusable as the result of law office failure, and that there was a meritorious defense of intrinsic fraud committed by the plaintiff, and therefore, they would affirm the Civil Court's order.

The relevant facts considered by the court in the case of D.A.V. Chiropractic, P.C. v American Tr. Ins. Co. were that the providers were seeking assigned first-party no-fault benefits. The main issue was whether the assignor of the benefits was eligible for workers' compensation benefits, and the court needed to determine the availability of compensation through the Workers' Compensation Board. The holding of the case was that because the Workers' Compensation Board has primary jurisdiction to determine factual issues concerning coverage under the Workers' Compensation Law, the matter needed to be remitted to the Board to be held in abeyance pending a prompt application to determine the parties' rights. The decision was ultimately made to reverse the judgment, vacate the order granting the providers' motion for summary judgment, and remit the matter to the Civil Court to be held in abeyance pending a prompt application to resolve the issues through the Workers' Compensation Board.

The pertinent facts of the case were that Manhattan Medical Imaging, P.C. moved for summary judgement to recover assigned first-party no-fault benefits. GEICO Ins. Co. opposed the motion on the grounds that the services rendered were not medically necessary. The Civil Court granted plaintiff's motion for summary judgment, and this appeal followed. However, the Appellate Term found that the defendant had provided enough evidence to demonstrate the existence of a triable issue of fact as to medical necessity. Consequently, the judgment was reversed, and plaintiff's motion for summary judgment was denied. Therefore, the main issue decided was whether the services rendered were medically necessary, and the holding of the case was that the defendant had provided sufficient evidence to demonstrate a triable issue of fact as to medical necessity, leading to the reversal of the judgment and denial of plaintiff's motion for summary judgment.