No-Fault Case Law

In this case, the plaintiff, A.M. Medical Services, sought to recover assigned first-party no-fault benefits from Progressive Casualty Insurance Company. The defendant moved for summary judgment to dismiss the complaint, arguing that the health care services attempted to be collected were rendered by independent contractors, and plaintiff was therefore not entitled to direct payment of benefits. The plaintiff's opposition was based on trial transcripts of three related actions against another insurance company that found plaintiff's treating providers were employees. The appellate court found that plaintiff's submission of claim forms stating that the billed-for services were rendered by independent contractors was sufficient evidence to award the defendant insurer summary judgment. The court determined that plaintiff did not supply proper proof of loss, and plaintiff's argument that their treating providers were employees was irrelevant. Therefore, the court affirmed the judgment without costs. In summary, the relevant facts considered by the court included the submission of claim forms and trial transcripts suggesting the health care services were rendered by employees. The main issue decided was whether an insurer could be awarded summary judgment based on defense that services were rendered by independent contractors, to which the court answered yes. The holding of the case was that claim forms stating services were rendered by independent contractors are sufficient evidence for an insurer to be awarded summary judgment.

The court considered the denial of the defendant's motion to vacate a judgment entered upon its default in appearing or answering the complaint, which was in favor of the plaintiffs and against it in the principal sum of $43,030.53. The defendant failed to demonstrate a reasonable excuse for the default. The plaintiffs established that they served the defendant through delivery of the summons and complaint upon the Assistant Deputy Superintendent and Chief of Insurance. The defendant did not contend that the address on file with the Superintendent of Insurance was incorrect, and the mere denial of receipt of the summons and complaint was insufficient to rebut the presumption of proper service created by the affidavit of service. Even if the defendant's motion were treated as one made pursuant to CPLR 317, it failed to meet its burden of showing that it did not receive actual notice of the summons in time to defend the action. The main issues decided were the denial of the defendant's motion to vacate a judgment entered upon its default, and the failure of the defendant to demonstrate a reasonable excuse for the default. The holding of the case was that the Supreme Court providently exercised its discretion in denying the defendant's motion to vacate the judgment.

The court in this case addressed the legality of the no-fault insurer's use of the prevailing geographic rate or the reasonable and customary rate for health care services in calculating first-party benefits due to a claimant or health-care provider. Globe Surgical Supply, as the assignee of Remy Gallant, commenced a class action lawsuit against GEICO Insurance Company for systematically reducing its reimbursement for medical equipment and supplies, specifically, durable medical equipment (DME), based on prevailing rate or the reasonable and customary rate. The court analyzed the no-fault statutory and regulatory scheme and the regulation 68 in relation to the reimbursement for DME, as well as the litigation that took place. The court denied the certification of the class action on behalf of all persons who had reimbursement payments of claims for medical equipment and supplies adjusted or reduced by GEICO to an amount less than the amount charged in the proof of claim, specifically to a "reasonable reimbursement of 150%."

The main issue in the case was whether the defendant insurance company was required to pay or deny the medical claims of two insured individuals within 30 days as prescribed by the relevant no-fault regulations. The plaintiff, Westchester Medical Center, sought summary judgment on the first cause of action regarding the claim of Josh Logan, arguing that the defendant failed to timely pay or deny the claim. The defendant, Clarendon National Insurance Company, had paid the claim of Edward Caruso and made a partial payment on the claim of Josh Logan. The court held that although the plaintiff demonstrated its entitlement to judgment as a matter of law on the first cause of action, the defendant raised a triable issue of fact as to whether it timely and properly denied the claim based on Logan's alleged intoxication at the time of the accident. Therefore, that branch of the plaintiff's motion for summary judgment on the first cause of action was denied.

The court was ruling on a case in which American Transit Insurance Company was suing to declare that they had no duty to defend and indemnify their insureds in a personal injury action brought by the defendant-appellant, Judith Klausner. The court upheld a previous decision to grant the insurer's motion for summary judgment. It was found that although the appellant had provided the insurer with information about the accident soon after it occurred, she did not provide notice of her suit against the insured until 14 months after the suit was commenced and had obtained an order for a default judgment. The disclaimer of coverage from the insurer was ruled as proper by the court. The court implicitly concluded that the insurer was required to show that it was prejudiced by the failure of appellant Klausner to provide timely notice of the action she had commenced against the insured. Despite timely notice of the accident, the insurer could still disclaim coverage based on untimely notice of the claimant's commencement of litigation unless it was prejudiced by the late notice. Therefore, appellant Klausner failed to exercise her independent right to fulfill the policy obligation of timely notice, and the insurer's disclaimer for lack of timely notice of the underlying action was upheld.

The court considered the relevant facts that the plaintiff commenced an action against the defendant to recover first-party no-fault benefits for medical services rendered, and the defendant moved to dismiss the complaint on the grounds that the plaintiff's assignor failed to appear for scheduled independent medical examinations (IMEs). The main issue decided was whether the insurance policy required the assignor to appear before a physician or any other healthcare provider. The court held that the insurance policy, although it stated "physician," required the assignor to appear before an independent medical examiner, which included physicians, surgeons, podiatrists, chiropractors, or psychologists. The court also determined that the defendant's request for verification was untimely, and thus the defense of failure to attend an IME was waived, and granted summary judgment in favor of the plaintiff.

The main issue in this case was whether the notice to admit from the provider was sufficient to establish a prima facie case for recovery of assigned first-party no-fault benefits. The court considered the provider's notice to admit, defendant's response, and oral arguments. The court held that the provider's notice to admit failed to establish a prima facie case, as they did not call any witnesses to lay a foundation to demonstrate that their claim form was admissible as a business record. The judgment of the Civil Court of the City of New York, Queens County, dismissing the complaint was affirmed by the appellate court. The court did not reach any other issue in the case.

The court considered a case in which a medical supplies company sought to recover first-party no-fault benefits through a settled action. Plaintiff entered into a stipulation of settlement with the defendant insurance company, and subsequently moved for an order to enter a judgment after settlement including provisions for additional interest and costs. However, the court denied the motion, as the plaintiff failed to prove its tender of the release and stipulation of discontinuance to the defendant. The main issue decided was whether the plaintiff had followed the requirements of CPLR 5003-a, which authorizes a settling plaintiff to enter judgment against a settling defendant who fails to pay all sums due within 21 days of tender of the release and stipulation. The holding was that the order denying the plaintiff's motion was affirmed due to the insufficient proof of tender to the defendant.

The court considered the fact that the plaintiff, a medical provider, was seeking to recover first-party no-fault benefits from the defendant insurance company for medical services provided to the defendant's insured. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint based on the insured's failure to appear for independent medical examinations (IMEs). The court held that the defendant was entitled to summary judgment because the chiropractor who was to perform the IME of the insured established that the insured failed to appear for the IME at the address set forth in the scheduling letters, and the plaintiff's argument was unsupported by the record. The court also found that the plaintiff's remaining contentions, raised for the first time on appeal, lacked merit. Therefore, the court upheld the decision of the lower court to grant the defendant's motion for summary judgment dismissing the complaint.

The relevant facts of the case were that A.M. Medical, P.C., as the assignee of Arkadiy Yusufov, sued State Farm Mutual Insurance Co. to recover assigned first-party no-fault benefits. State Farm moved to dismiss the case based on A.M. Medical's failure to take action in the lawsuit, and the court granted the motion. A.M. Medical argued that the demand to dismiss the case was defective because it did not contain the required caption setting forth the name of the court, venue, and index number of the action. However, the court found that the omissions were merely defects in form that could have been objected to by returning the demand to the defendant, specifying the nature of the defect. A.M. Medical's failure to do so waived any objection to the defect. Therefore, the court affirmed the judgment dismissing the complaint.