No-Fault Case Law

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.

The relevant facts the court considered included an action by a medical supplies provider to recover assigned first-party no-fault benefits. The defendant had granted the motion for summary judgment dismissing the complaint on the grounds that the plaintiff's assignor had failed to appear for scheduled independent medical examinations. The main issue decided by the court was whether the defendant had properly mailed the denial of claim forms in duplicate and whether the affirmation of the plaintiff's counsel in opposition to the defendant's motion was sufficient to raise a triable issue of fact. The holding of the case was that the defendant had properly mailed the denial of claim forms and that the affirmation of the plaintiff's counsel was insufficient to raise a triable issue of fact. Therefore, the court affirmed the order granting the defendant's motion for summary judgment.

The court considered the appeal from a judgment of the Civil Court of the City of New York, Kings County, which awarded the plaintiff, Adelaida Physical Therapy, P.C., the principal sum of $4,181.20 after a nonjury trial in a case involving a provider seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the judgment should be reversed and the matter remitted to the Civil Court for the entry of a judgment in favor of the defendant, Lancer Insurance Co., dismissing the complaint. The holding of the court was that, for the reasons stated in a related case (JCC Med. P.C., as Assignee of Damis, Magalie v Lancer Ins. Co.), the judgment was reversed and the matter was remitted to the Civil Court for the entry of a judgment in favor of the defendant, dismissing the complaint.

The main issue in this case was whether the provider, New Way Medical Supply Corp., was entitled to recover assigned first-party no-fault benefits from Lancer Insurance Co. After a nonjury trial, the Civil Court of the City of New York, Kings County, entered a judgment in favor of New Way Medical Supply Corp., awarding them the principal sum of $3,048.40. However, on appeal, the Appellate Term, Second Department, reversed the judgment and remitted the matter to the Civil Court for the entry of a judgment in favor of Lancer Insurance Co., dismissing the complaint. The court's decision was based on the same reasoning as another related case, JCC Med. P.C., as Assignee of Damis, Magalie v Lancer Ins. Co. The holding of the case was that the judgment in favor of New Way Medical Supply Corp. was reversed, and the matter was remitted to the Civil Court for the entry of a judgment in favor of Lancer Insurance Co., dismissing the complaint.