No-Fault Case Law

The court considered that the plaintiff, Alsaad Medical, P.C., sought payment of no-fault benefits for medical treatments for assignor Patronita Colon-Chavez under the defendant's insurance policy. The plaintiff had treated Colon-Chavez for injuries sustained in a motor vehicle accident and sought payment of $200.68 for the services provided. The defendant, State Farm Mutual Automobile Insurance Co., moved for summary judgment and dismissal of the action on the grounds that the plaintiff failed to appear for two scheduled Examinations Under Oath (EUOs) and, therefore, its claims for medical services were appropriately denied. The plaintiff argued that the EUO notices were defective and that its submissions, objecting to the EUOs, obviated the need to appear. In its decision, the court granted the defendant's motion for summary judgment and dismissed the action, while denying the plaintiff's cross-motion for summary judgment on the grounds that more than 30 days had elapsed since submitting its claims and the defendant had failed to pay them. The court also noted that pursuant to the No-Fault Law, entitlement to no-fault benefits requires compliance with all conditions precedent, including the timely submission of written proof of claim. Therefore, the defendant was authorized to deny the claim due to the plaintiff's failure to comply with these requirements.

The court considered the fact that the plaintiff, Burke 2 Physical Therapy, P.C., submitted bills for treatment to the defendant, State Farm Mutual Automobile Insurance Co., after the insured, Sang, was in a motor vehicle accident. Despite acknowledging receipt of the claims, State Farm issued several verification requests and denials of the claims. The main issue decided was whether State Farm's verification requests were proper, timely, and justified, and if Burke was in compliance with providing the requested verification. The court held that State Farm's verification requests were proper, timely, and justified, and that Burke failed to comply with providing the requested verification, leading to the dismissal of the plaintiff's complaint and the grant of State Farm's motion for summary judgment.

The relevant facts considered by the court included the filing of a summons and complaint by a provider to recover assigned first-party no-fault benefits in Civil Court, Kings County, which indicated that the matter was to be heard in Civil Court, Queens County. The defendant served an answer and allegedly filed it in Queens County. The plaintiff then moved for a default judgment, which was granted, and a judgment was entered. The defendant then moved to vacate the default judgment and dismiss the complaint, arguing that the Civil Court, Kings County, did not have jurisdiction over the matter. The Civil Court granted the motion, vacated the default judgment, and dismissed the plaintiff's complaint as "fatally defective." The main issue decided by the court was whether dismissal of the complaint was the proper remedy upon the vacatur of the default judgment, or if the plaintiff should have been permitted to correct its error pursuant to CPLR 2001. The holding of the court was that the plaintiff's argument that it should have been afforded an opportunity to amend the complaint pursuant to CPLR 2001 was unpreserved for appellate review, as the plaintiff failed to raise the issue in opposition to the defendant's motion. Therefore, the order, insofar as appealed from, was affirmed.

The relevant facts considered in this case were that State Farm Mutual Automobile Insurance Company submitted evidence of the defendants' defaults after proper service, as well as an affidavit of its no-faults claims representative setting forth the basis for its claims seeking a declaration of noncoverage in connection with a June 1, 2018 accident. By failing to answer the complaint, the defaulting defendants were deemed to have admitted the allegations, including that the accident was intentional and staged. Also, State Farm's claims representative's affidavit and red flags raised by defendant Walton's testimony supported the company's belief. The main issue decided was whether the company was entitled to a declaration that it was not obligated to defend or indemnify the owner of the insured vehicle, or the driver, or to provide no-fault coverage to any of the claimants in connection with the accident. The holding of the case was that the motion for a default judgment was granted in its entirety and it was declared that State Farm was not obligated to provide coverage for the accident.

The relevant facts that the court considered in this case included the circumstances surrounding responses to verification requests regarding MRI films sent in response to claims for no-fault benefits. Defendant in the case moved for summary judgment to dismiss the complaint, arguing that the action was premature as plaintiff had not provided the MRI films demanded. The issue decided by the court was whether the toll on the insurer's time to pay or deny a claim ends when the provider responds that the films will be sent only after the insurer reimburses the provider for the reproduction costs of those films. The court's holding was that the action was in fact premature, and the plaintiff had not complied with the verification requests to provide MRI films, and the insurer was not required to pay the reproduction costs to receive the films. Therefore, the action was dismissed as premature.

The case of American Tr. Ins. Co. v Espinal involved a motion for summary judgment in a case where the plaintiff sought a declaration that they were not obligated to pay no-fault benefits to the defendant, Samuel O. Espinal. The defendant had timely filed opposition to the summary judgment motion in accordance with CPLR 2214 (b). However, the motion court had granted the plaintiff's motion on the ground that the defendant failed to submit opposition papers, without considering the merits of the motion. Therefore, the main issue decided was whether the matter should be remanded for the motion court to consider the merits of the summary judgment motion. The holding of the Appellate Division, First Department was that the matter should be remanded for further proceedings for the motion court to consider the merits of the summary judgment motion in the first instance.

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 a case where a provider sought to recover assigned first-party no-fault benefits. The main issue was whether the plaintiff's affidavit submitted in opposition to the defendant's motion was sufficient to rebut the defendant's showing of a lack of medical necessity for the services at issue. The holding of the court was that the plaintiff's affidavit was insufficient to rebut the defendant's prima facie showing of a lack of medical necessity for the services at issue, and therefore affirmed the order granting the defendant's motion for summary judgment.

The relevant facts the court considered were that the plaintiff, Country-Wide Insurance Company, sought a declaratory judgment that it was not liable to pay no-fault benefits to medical-provider assignees due to the failure of the driver, Saquan Ware, to appear for scheduled independent medical examinations (IMEs). Country-Wide had requested the IMEs within the appropriate time frames as required by regulations and Ware had failed to appear for the examinations as scheduled. The main issue decided was whether Country-Wide timely requested Ware to appear for the IMEs, and the holding of the case was that Country-Wide had established that Ware failed twice to appear for properly scheduled IMEs, therefore voiding his insurance coverage ab initio and relieving Country-Wide from liability to pay the no-fault benefits. As a result, Country-Wide's motion for summary judgment was granted.

The relevant facts in this case involved a plaintiff suing an insurance company to recover unpaid first-party no-fault benefits for medical services provided to their assignor. The insurance company moved for summary judgment on the grounds that the assignor failed to appear for two independent medical examinations (IME). The main issue decided by the court was whether the insurance company had timely denied the plaintiff's claims based on the assignor's failure to attend the IMEs, which was a condition precedent to the insurer's liability on the policy. The court held that the insurance company presented sufficient evidence to demonstrate that it timely denied the plaintiff's claims based on the assignor's failure to attend the IMEs, and the plaintiff failed to raise factual issues requiring a trial. As a result, the court granted the insurance company's motion for summary judgment and dismissed the plaintiff's complaint.

The court considered a personal injury protection insurance claim in which the plaintiff sued the defendant for unpaid medical services provided to an individual injured in a car accident. The defendant moved for summary judgment, arguing that the plaintiff failed to provide additional documentary verification within the required time frame. In response, the plaintiff cross-moved for summary judgment on its claims against the defendant. The main issue decided by the court was whether the plaintiff's failure to provide requested verification within the required time frame warranted the dismissal of the plaintiff’s complaint and whether the defendant properly advised the plaintiff of the consequences for noncompliance. The court held that the defendant failed to establish its entitlement to summary judgment as there was a disputed issue of fact regarding the plaintiff's eligibility to receive insurance benefit payments. As a result, the court denied both the defendant’s motion for summary judgment and the plaintiff’s cross-motion.