No-Fault Case Law

The relevant facts that were considered in this case were that the plaintiff, a New Jersey medical provider, sought to recover first-party no-fault benefits against the defendant, an insurance company, for medical services provided to an individual injured in a motor vehicle accident. The plaintiff alleged that the insured assigned first-party no-fault benefits to it but the defendant had failed to pay for the medical services. The main issue decided in this case was whether the defendant was entitled to summary judgment dismissing the complaint on the grounds that the claimed expenses were not medically necessary and that one particular expense was not reimbursable under the applicable New Jersey medical fee schedule for Automobile Insurance Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage. The holding of the court was that the defendant failed to make a prima facie showing that the services provided were not medically necessary and that the disputed surgical device was not reimbursable, thus raising a triable issue of fact as to medical necessity and the eligibility of the disputed device for reimbursement. Therefore, the Supreme Court's determination denying the defendant's motion for summary judgment dismissing the complaint was affirmed.

The court considered the case of Madison Products of USA, Inc. as assignee of Pierre, Luxio against American Transit Ins. Co. The main issue decided was whether workers' compensation benefits might be available to the plaintiff's assignor, who had been injured during the course of his employment at the time of the accident. The court held that there was an issue as to whether the plaintiff's assignor had been acting in the course of his employment at the time of the accident, and that the determination of the applicability of the Workers' Compensation Law was vested in the Workers' Compensation Board. As a result, the court modified the order to hold the plaintiff's motion in abeyance until it is ripe for determination, and remitted the matter to the Civil Court for a new determination, following a framed issue hearing, of the branch of defendant's cross motion seeking to hold the fifth cause of action in abeyance pending a determination by the Workers' Compensation Board of the parties' rights under the Workers' Compensation Law.

The court considered the facts that the insurance company timely denied the claims due to the plaintiff's failure to appear for scheduled examinations under oath (EUOs) and that the initial EUO scheduling letter identified the assignor, the accident date, and the defendant's file number. The main issue decided was whether the EUO scheduling letters were defective, and if the plaintiff had failed to appear for the scheduled EUOs. The holding of the case was that the judgment was reversed, the order denying defendant's motion for summary judgment was vacated, the defendant's motion for summary judgment dismissing the complaint was granted, and plaintiff's cross motion for summary judgment was denied. The insurance company had timely denied the claims due to the plaintiff's failure to appear for the EUOs, and the plaintiff failed to raise a triable issue of fact in opposition.

In the case Longevity Med. Supply, Inc. v Progressive Ins. Co., the court considered the fact whether Progressive Insurance Company was liable to pay no-fault benefits to Longevity Medical Supply, Inc. which was the assignee of Saddiq Waiters, who was involved in a motor vehicle accident. The main issue in the case was the failure of Saddiq Waiters to appear for an independent medical examination (IME) scheduled on two occasions as required by Progressive Insurance Company to process the claim. The court held that Progressive Insurance Company met its prima facie burden to establish that it properly mailed scheduling letters for IMEs, but failed to establish that the claimant failed to appear for the IMEs. Therefore, the court denied the defendant's motion for summary judgment. The court found that both affidavits submitted by the defendant were insufficient and the defendant had not met its burden to establish that the claimant failed to appear for the IME.

The court considered the fact that the plaintiff filed an action against the defendant seeking to recover $5,503.90 in assigned no-fault insurance benefits. The main issues decided were whether the plaintiff had standing to receive the reimbursement, the medical necessity of the treatment, and the proper payment under the fee schedule. The court held that the plaintiff did have standing to receive reimbursement, denied the defendant's motion on the Mallela defense, found a material issue of fact exists as to the medical necessity of the treatment, and denied the defendant's motion for summary judgment as to the proper payment under the fee schedule. The plaintiff's cross motion for summary judgment was also denied in its entirety.

The case involved an appeal from a judgment entered in a Civil Court of New York, in which the court granted the plaintiff's motion for a default judgment and denied the defendant's cross-motion for summary judgment dismissing the complaint. The plaintiff, a provider seeking to recover assigned first-party no-fault benefits, alleged that the summons and complaint were served by mail, but failed to provide proof of proper service. The defendant argued that the complaint should be dismissed due to the plaintiff's failure to serve the summons and complaint within 120 days of commencing the action. The Appellate Court reversed the judgment, vacated the order, and granted the defendant's cross-motion for summary judgment, remitting the matter to the Civil Court for the entry of a judgment in favor of the defendant dismissing the complaint without prejudice. The court emphasized that proof of proper service was a prerequisite to the entry of a default judgment, and plaintiff's failure to provide evidence of service led to the reversal of the judgment.

The court considered the plaintiff's delay in prosecuting the action as a basis for dismissal. The main issue decided was whether laches was a proper basis to dismiss the complaint in this action to recover assigned first-party no-fault benefits. The holding was that laches was not a proper basis to dismiss the complaint in this action, and therefore the branch of the defendant's motion seeking dismissal on the ground of laches was denied. The matter was remitted to the Civil Court for a determination of the remaining branches of the defendant's motion.

The relevant facts considered by the court were that TAM Medical Supply Corp. sought to recover first-party no-fault benefits from Republic Western Insurance Company, but Republic argued that the action was barred by the doctrine of res judicata due to a previous order granting a default judgment against TAM and its assignor. TAM submitted late opposition papers to Republic's motion for summary judgment, and the Civil Court granted Republic's motion without considering TAM's late opposition. TAM then moved to vacate the order, claiming a reasonable excuse for submitting the opposition papers late and a meritorious claim of breach of contract. The court determined that TAM's explanation of law office failure was insufficient, and therefore denied TAM's motion to vacate the order. The holding of the case was that the order denying TAM's motion was affirmed.

The main issue in this case was whether the supplies at issue were medically necessary. The court considered the fact that the defendant's expert witness was precluded from testifying at the non-jury trial because of untimely disclosure, and the plaintiff was awarded $12,182.91 after the trial. The appellate court decided that precluding the defendant's expert from testifying was in error, as there was no evidence of intentional or willful failure to disclose and no showing of prejudice by the opposing party. The court held that the matter needed to be remitted to the Civil Court for a new trial limited to the issue of medical necessity, and that the defendant's expert should not have been precluded from testifying.

The main issue in this case was the entry of a default judgment in favor of the plaintiff, Freedom Chiropractic, P.C., for no-fault benefits for services provided to Ludmilla Dejean, who was injured in a motor vehicle accident. The defendant, 21st Century Insurance Company, argued that it did not receive proper notice of the motion for the entry of the default judgment, and therefore the judgment was null and void. The Supreme Court had previously issued a declaratory judgment, determining that 21st Century was not obligated to reimburse Freedom Chiropractic and Dejean for claims arising from the accident, and that the insurance policy was null and void with respect to that accident. The court ultimately held that the defendant demonstrated an excusable default and a meritorious defense to the action, and therefore granted summary judgment dismissing the complaint. The order granting summary judgment to the defendant was affirmed by the Appellate Term.