No-Fault Case Law

The court considered the issue of whether the supplies provided to the plaintiff's assignor were medically necessary in a case involving a claim for first-party no-fault benefits. The defendant made a prima facie showing of entitlement to summary judgment by establishing the timely mailing of the claim denial form and submitting an affirmed peer review report of its doctor, which concluded that there was a lack of medical necessity for the supplies provided. The Civil Court granted the defendant's motion for summary judgment, and the plaintiff's opposition papers failed to rebut the showing that the supplies were not medically necessary. As a result, the court affirmed the order without costs, holding that the defendant's motion for summary judgment dismissing the complaint was properly granted, as the plaintiff failed to rebut the defendant's prima facie showing.

The court considered the denial of a claim for first-party no-fault benefits by the defendant insurance company, which was based on the lack of medical necessity for the services in question. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint brought by the plaintiff, a provider seeking to recover assigned first-party no-fault benefits. The holding of the case was that the defendant insurance company had established its prima facie entitlement to summary judgment by timely mailing denial of claim forms and submitting an affidavit and peer review report demonstrating the lack of medical necessity for the services. The plaintiff failed to raise a triable issue of fact, and therefore the defendant's cross motion for summary judgment dismissing the complaint should have been granted.

The court considered the fact that the plaintiff failed to timely provide ordered discovery responses, resulting in the defendant's motion for summary judgment dismissing the complaint on the ground that the plaintiff was precluded from offering any evidence or testimony at trial. The main issue was whether the so-ordered stipulation functioned as a conditional order of preclusion, and if plaintiff had a reasonable excuse for the failure to comply with the stipulation and the existence of a meritorious cause of action. The court held that the conditional order of preclusion became absolute upon plaintiff's failure to sufficiently and timely comply, and as the plaintiff failed to demonstrate a reasonable excuse for the failure to comply, the Civil Court properly granted the defendant's motion for summary judgment. Therefore, the judgment was affirmed.

The relevant facts in this case include the plaintiff's failure to comply with a previous court ordered stipulation to serve complete verified responses to written discovery demands. The stipulation stated that failure to comply would result in the plaintiff being precluded from offering evidence or testimony at trial. After over a year had passed without plaintiff providing the ordered discovery responses, the defendant moved to dismiss the complaint on the ground that the plaintiff was precluded from offering evidence or testimony at trial and could not establish a prima facie case. In opposition, the plaintiff offered no excuse for its failure to comply with the so-ordered stipulation, only stating that it had finally served the requested responses after the defendant made the motion. The main issue decided in this case was whether the plaintiff's failure to comply with the so-ordered stipulation, which functioned as a conditional order of preclusion, justified the defendant's motion to dismiss the complaint. The court held that the plaintiff's failure to demonstrate a reasonable excuse for the failure to timely comply with the stipulation and the existence of a meritorious cause of action, as required by the conditional order of preclusion, justified the dismissal of the complaint.

The relevant facts the court considered were that the appellant was trying to recover first-party no-fault benefits from the respondent. The respondent moved for summary judgment to dismiss the complaint, which was granted, and denied the appellant's cross-motion for summary judgment. The issues decided was whether the denial of claim forms were mailed, and whether the appellant's assignor failed to appear for scheduled examinations. The holding of the case was that the respondent's motion for summary judgment was properly granted, and the appellant's cross motion was properly denied. The appearance of the appellant's assignor at an examination under oath was a condition precedent to the respondent insurer's liability. Therefore, the respondent's motion was properly granted and the appellant's cross motion was properly denied.

The court considered the defendant's motion for summary judgment dismissing the complaint in an action to recover assigned first-party no-fault benefits. The claims pertained to assignors Eridania Hiraldo, Manuel Espinal, and Milton Williams. The main issues decided were whether there was coverage for the claims made by Hiraldo and Espinal, and whether the denial of claim forms constituted evidence inadmissible form pursuant to the business records exception to the rule against hearsay. The court held that the denial of claim forms and the notice of cancellation offered by the defendant did not need to qualify as business records, as they were not being offered for a hearsay purpose. As a result, the order granting defendant's motion for summary judgment was affirmed.

The court considered a case where a provider was seeking to recover assigned first-party no-fault benefits. The main issue was whether, within one year of the accident, it was ascertainable that further expenses may be incurred as a result of the injury. The Civil Court concluded that further expenses were ascertainable because the injured party had submitted an application for no-fault benefits within two months of the accident. However, the court found that the stipulated facts did not cover all relevant points of dispute, specifically whether the injured party received any relevant treatment and incurred any relevant expenses within the one-year period following the accident. Therefore, the court reversed the judgment and remitted the matter to the Civil Court where the parties could stipulate to a more definite statement of facts or proceed to trial on the disputed issue in accordance with the decision.

The court considered that on September 1, 2007, Vitaly Polyakov was involved in a motorcycle accident and was injured. Polyakov reported to the police officer who responded to the scene that an unidentified vehicle struck his motorcycle. At the time of the accident, Mikhail Polyakov, Vitaly's father had a policy of automobile insurance. New York Central Mutual Fire Insurance Company denied the claim for supplementary uninsured/underinsured motorists benefits that Polyakov filed, on the grounds that the motorcycle he was riding at the time of the accident was not an insured vehicle under the subject policy. Polyakov demanded arbitration and the court held that the petition should have been granted, based on the policy language that was not ambiguous. The court found that the Sum endorsement under the subject policy specifically excluded coverage for injury to an insured while occupying a motor vehicle owned by that insured, if such motor vehicle is not insured for Sum coverage by the policy under which a claim is made.

The court in this case had to decide on a motion to reargue the court's decision regarding the timeliness of the defendant's denial of plaintiff's claim. Plaintiff Jesa Medical Supply, Inc. sought payment of first-party no-fault benefits from defendant American Transit Insurance Co. The court held that the defendant's denial was one day late, not two days late because Presidents' Day, a legal holiday, should have been excluded in computing the time needed for the verification request. According to 11 NYCRR 65-3.5 (b) and 11 NYCRR 65-3.8 (j), defendant's request for additional verification within 15 business days would exclude legal holidays from the calculation of the number of days required to submit the additional verification requests. Therefore, the motion to reargue was granted, and the case was set down for trial on the sole issue of medical necessity.

The court considered the defendant's motion for summary judgment dismissing the complaint, based on the fact that they had made a prima facie showing that two separate requests for an independent medical examination ("IME") of plaintiff's assignor were duly mailed to the assignor and that the assignor failed to appear for the examination. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint, and the court held that they were. The court noted that the defendant was not required to produce the applicable automobile insurance policy in order to establish that the mandatory personal injury endorsement included an IME provision. Therefore, the defendant's motion for summary judgment was granted and the complaint was dismissed.