No-Fault Case Law

The relevant facts that the court considered in this case were that A.R. Medical Art, P.C. sought to recover fees for EMG/NCV tests performed on a patient, Nato Seselia. State Farm Mutual Automobile Insurance Company denied payment, claiming the tests were medically unnecessary. The main issue decided by the court was whether the EMG/NCV tests were necessary, with State Farm bearing the burden of proof. The holding of the case was that the insurer failed to show that the tests were inconsistent with generally accepted medical practices and were therefore medically unnecessary. As a result, the court rendered judgment in favor of the plaintiff and against the defendant in the sum of $2,143.90.

The relevant facts the court considered were that the plaintiff had failed to respond to certain discovery demands, resulting in the dismissal of the complaint in February 2005. The main issue decided was whether Supreme Court erred in granting relief to the plaintiff after she failed to appeal the dismissal of the complaint, and whether a motion to vacate pursuant to CPLR 5015 (a) (1) was appropriate. The holding of the court was that the default that the plaintiff sought to vacate was her default in opposing the defendant's motion to preclude in the first instance, and therefore, Supreme Court did not err in entertaining her motion to vacate. The court affirmed the order with costs.

The court considered an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignor. The main issues decided were whether the plaintiffs were entitled to partial summary judgment for their claim, and whether the defendant's discovery demands should be granted. The court held that the plaintiffs were entitled to partial summary judgment, as they established their entitlement to the benefits, and the defendant's assertion that it timely denied the claims lacked merit. However, the court also ordered a hearing to determine the plaintiffs' compliance with licensing requirements, as the defendant was entitled to information regarding the corporate structure and licensing status of the plaintiffs. The court also granted the defendant's cross motion to determine the genuineness of the signature of the plaintiffs' counsel on various papers submitted in the case.

The court considered the fact that plaintiff PDG Psychological P.C. was seeking to recover first-party no-fault benefits for health care services rendered to its assignor, Gloria Jones. Defendant Utica Mutual Insurance Company moved for summary judgment dismissing the complaint, while plaintiff cross-moved for summary judgment. The main issue decided was whether plaintiff was entitled to rely upon defendant's denial of claim forms to establish the dates of defendant's receipt of the claim forms, and whether defendant mailed the denial of claim forms to plaintiff within the prescribed 30-day claim determination period. The holding was that plaintiff established a prima facie entitlement to summary judgment, and since defendant failed to establish that it mailed the denial of claim forms to plaintiff within the prescribed 30-day claim determination period, it was precluded from raising its defenses and the court properly granted plaintiff's cross motion for summary judgment.

The court considered the case of Star Medical Services, P.C. v Allstate Insurance Company, pertaining to the recovery of first-party no-fault benefits for medical services that were rendered. The main issue was whether the plaintiff health care provider had established a prima facie entitlement to summary judgment through proof of submitting claims and the overdue payment of no-fault benefits. The decision held that plaintiff was entitled to summary judgment in the principal sum of $1,791 with respect to the claims submitted on behalf of Naika Gousse. The matter was remanded to the court for calculation of statutory interest and attorney's fees due on those claims, as well as for all further proceedings on the remaining claims submitted on behalf of Jimmy Cadet. Additionally, the court concluded that the defendant failed to follow the requisite follow-up verification procedures and that claim denials based upon nonattendance for examinations under oath were ineffective. Finally, it was determined that the defendant's submissions were legally sufficient to support the allegations that the injuries did not arise out of an insured incident for the claims submitted on behalf of Jimmy Cadet.

The court considered a motion to vacate a default judgment entered against Allstate Insurance Company in an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignor. The main issues decided were whether the defendant established a reasonable excuse for the default and a meritorious defense to the action. The court held that the lower court had improvidently exercised its discretion in granting defendant's motion to vacate the default judgment. It was determined that the defendant did not show a reasonable excuse for the default and failed to sufficiently establish a meritorious defense. The court found that the defendant's moving papers did not include an affidavit by someone with personal knowledge of the underlying circumstances, and therefore did not meet the necessary burden of proof.

The case of East Coast Medical Care, P.C. v State Farm Mutual Auto. Ins. Co. involved a first-party claim for benefits under New York's No-Fault Insurance Law. After evidence was heard in the case, the presiding judge was unexpectedly reassigned from civil to criminal court, making it impossible to continue the trial. Neither party moved for a mistrial, and the determination that a mistrial was necessary was made by the court. The main issue was whether a court can declare a mistrial sua sponte over a party's objections when it becomes impossible for the trial judge to continue hearing the case. The court held that the decision as to whether or not to grant a new trial lies in the discretion of the court when a trial cannot proceed without injustice to a party, and in this case, the interests of justice required the declaration of a mistrial because evidence had been heard, no other judge could be substituted, and an indefinite continuance would be impracticable.

The relevant facts in this case were that Vista Surgical Supplies, Inc. was seeking to recover first-party no-fault benefits for medical supplies provided to its assignor. The main issue was whether Vista Surgical Supplies, Inc. had submitted its claim form to Allstate Insurance Co. The court held that Vista Surgical Supplies, Inc. did not establish its prima facie entitlement to summary judgment because it failed to conclusively show that it submitted its claim form to Allstate Insurance Co. The court also held that the provision of the order awarding defendant $250 in costs should be deleted. The decision was that Vista Surgical Supplies, Inc.'s motion for summary judgment was properly denied, and Allstate Insurance Co.'s cross motion for summary judgment should be denied, thus affirming the order without costs.

The court considered the fact that the plaintiff had submitted a statutory claim form for first-party no-fault benefits for medical services provided to the injured assignor. The main issue decided was whether the defendant had established that verification requests were timely mailed. The court held that the defendant failed to prove the timely mailing of the verification requests and did not create a presumption of mailing by providing evidence of the standard operating procedures used to ensure that the verification requests were mailed. As a result, the court affirmed the order granting the plaintiff's motion for summary judgment and denying the defendant's cross motion.

The court considered the fact that Ocean Diagnostic Imaging had submitted claims for first-party no-fault benefits for medical services rendered to its assignors for injuries sustained in accidents in February and May 2003. The main issue decided was whether Ocean Diagnostic Imaging had established its entitlement to summary judgment by submitting claims and whether the insurance company had waived any defenses by failing to seek verification of the assignments. The holding of the case was that Ocean Diagnostic Imaging had established its entitlement to summary judgment and that the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees. The court also emphasized the principle that once a party affirmatively establishes an issue of fact, the other side must oppose it either factually or on legal grounds, or else that issue will be determined in favor of the proponent.