No-Fault Case Law

The main issue in this case was whether defendant's denial of claim forms were timely. The Civil Court concluded that the denials could not be timely because they were based upon the assignor's failure to appear for independent medical examinations (IMEs) and were mailed more than 30 days after that failure to appear. However, the Appellate Term held that the Civil Court's holding was erroneous, and that an insurer need not deny a claim while it is waiting for requested verification even if it already has a basis to deny it. As no testimony was taken from defendant's witness, the matter was remitted to the Civil Court for a new trial. Therefore, the order denying defendant's motion to set aside the decision of the Civil Court and the judgment entered pursuant thereto was reversed, and the matter was remitted to the Civil Court for a new trial.

The court in this case considered the defendant's motion for summary judgment to dismiss the complaint on the grounds of lack of medical necessity for the supplies at issue, untimely submission of claims, and exceeding the workers' compensation fee schedule amounts. The court also considered the plaintiff's cross-motion for summary judgment. The main issue decided was whether there were triable issues of fact as to the medical necessity of the supplies and timely submission of claims, and whether the trial should be limited to the issue of the fee schedule. The holding was that the defendant was not entitled to summary judgment dismissing the complaint, and there was no basis for the court to find that the claims had been timely and properly mailed or to limit the trial to the issue of the fee schedule. Therefore, the implicit CPLR 3212 (g) finding in plaintiff's favor and the limitation of the trial to the fee schedule were vacated.

The main issue in this case was whether or not the defendant was entitled to summary judgment dismissing the complaint on the ground that the plaintiff had failed to provide requested verification in a first-party no-fault benefits action. The defendant had demonstrated that they had timely mailed initial and follow-up requests for verification and that they had not received the requested verification, and had timely denied the plaintiff's claims on that ground. However, the affidavit submitted by the plaintiff in opposition to the defendant's motion was sufficient to give rise to a presumption that the requested verification had been mailed to, and received by, the defendant. As a result, the court found that there was a triable issue of fact as to whether the plaintiff provided the requested verification. Therefore, the judgment was reversed and the order granting the plaintiff's cross-motion for summary judgment was vacated, and the plaintiff's cross-motion for summary judgment was denied.

The main issue in the case was whether or not the defendant, Global Liberty Ins. of NY, had properly paid the claims for services rendered by Master Cheng Acupuncture, P.C. According to defendant's proof, they had paid the claims in accordance with the worker's compensation fee schedule. The court agreed with the defendant's argument and found that there was no triable issue of fact with respect to this branch of defendant's motion. However, the court did find a triable issue of fact regarding the medical necessity of the services rendered on May 23, 2014. Therefore, the court modified the order to provide that the branch of defendant's motion seeking summary judgment dismissing the unpaid portion of plaintiff's claims for services rendered from April 17, 2014, through May 12, 2014, is granted.

The relevant fact considered by the court in this case was whether the defendant had received the claim forms underlying the plaintiff's second and third causes of action. The main issue decided in this case was whether the defendant had received the claim forms at issue. The holding of the court was that the defendant had submitted sufficient proof to demonstrate, prima facie, that it had not received the claim forms, but the affidavit of the plaintiff's billing administrator raised an issue of fact as to whether those claim forms had been mailed to the defendant. Therefore, the court held that there was an issue of fact as to whether the defendant had received the claims at issue, and consequently denied the branches of the plaintiff's motion seeking summary judgment upon the second and third causes of action.

The court considered the facts that the defendant, Ameriprise Insurance, had timely mailed initial and follow-up letters scheduling an examination under oath, which the plaintiff's assignor had failed to appear for. The defendant had also timely denied the claims on that ground. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint for failure to appear for the examination under oath. The holding of the court was that the defendant's motion for summary judgment was granted, and the plaintiff's cross motion for summary judgment was denied. Therefore, the complaint was dismissed.

The court considered the fact that the plaintiff, Silver Lotus Acupuncture, P.C., was seeking to recover assigned first-party no-fault benefits, but the defendant, Global Liberty Ins. Co. of NY, had moved for summary judgment dismissing the complaint on the grounds that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs). The court determined that the record was sufficient to establish the proper mailing of the IME scheduling letters to the plaintiff's assignor and that the assignor had indeed failed to appear for the scheduled IMEs. The main issue decided was whether the plaintiff had satisfied the requirements for the assigned first-party no-fault benefits, and the holding was that the defendant's motion for summary judgment was granted because the plaintiff's assignor had failed to appear for the scheduled IMEs. The court affirmed the order, with costs, and the decision was entered on November 13, 2020.

The court considered the fact that the plaintiff, NL Quality Medical, P.C., was seeking to recover assigned first-party no-fault benefits, and that defendant, GEICO Ins. Co., had moved for summary judgment to dismiss the complaint on the basis that the plaintiff had failed to appear for scheduled examinations under oath (EUOs). The main issue was whether the plaintiff had indeed failed to appear for the scheduled EUOs. The court held that the defendant had submitted sufficient proof to demonstrate that the plaintiff had failed to appear for the EUOs, and that the plaintiff had failed to rebut this showing. Additionally, the court found that the defendant had provided sufficient proof that the EUO scheduling letters and denial of claim forms had been timely mailed, and therefore granted the defendant's motion for summary judgment dismissing the complaint.

The court considered a motion for summary judgment dismissing the complaint by the defendant, who argued that the claims at issue were properly denied due to the plaintiff's failure to provide requested verification within 120 days after the initial request. The main issue decided was whether the defendant demonstrated that it had not received all of the requested verification, and if the dismissal of the complaint without prejudice was appropriate. The holding of the court was that the defendant demonstrated prima facie that it had not received all of the requested verification, and as the order dismissed the complaint without prejudice, the plaintiff's remaining contention was deemed academic. The court affirmed the order, with costs.

The relevant facts in this case include an action by a provider to recover assigned first-party no-fault benefits. The defendant alleged that the amount of available coverage had been exhausted after partially denying the claims that are the subject of the action and making subsequent payments. However, the court found that this allegation did not warrant summary judgment dismissing the complaint on the basis of an exhaustion of available coverage defense. The defendant also argued that it had fully paid the claims in accordance with the workers' compensation fee schedule, but failed to demonstrate, as a matter of law, that the fees charged exceeded the amount set forth in the workers' compensation fee schedule. Therefore, the court reversed the order and denied defendant's motion for summary judgment dismissing the complaint. The main issue decided in this case was whether the defendant's allegations of exhausting the available coverage and fully paying the claims in accordance with the workers' compensation fee schedule warranted summary judgment dismissing the complaint. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was denied because the allegations did not warrant such a dismissal.