No-Fault Case Law

The main issue in the case was whether the insurer's denial of claim forms had been timely mailed, and whether the claims at issue had been timely denied. The court found that the insurer's papers failed to establish, as a matter of law, that the denial of claim forms had been timely mailed, and therefore, the insurer did not demonstrate that it is not precluded from asserting its proffered defenses. However, the court also found that the plaintiff failed to establish that the claims at issue had not been timely denied, or that the insurer had issued timely denials of claim that were conclusory, vague or without merit as a matter of law. As a result, the court modified the lower court's order to provide that the insurer's cross motion for summary judgment dismissing the complaint is denied, and affirmed the order as modified.

The relevant facts in the case are that the appellant, Apple Massage Therapy, was seeking to recover assigned first-party no-fault benefits from 21st Century Ins. Co. The defendant, 21st Century Ins. Co., filed a motion for summary judgment dismissing the complaint, which was granted by the Civil Court. The main issue decided in this case was whether the proof submitted by the defendant was sufficient to demonstrate that the denial of claim forms had been properly mailed and to show that the defendant had properly used the workers' compensation fee schedule to determine the amount plaintiff was entitled to receive. The holding of this case was that the order granting the defendant's motion for summary judgment dismissing the complaint was affirmed. The court found that the defendant's proof was sufficient to establish a presumption that the denial of claim forms had been properly mailed and that the defendant had properly used the fee schedule.

The facts of the case are that a psychological services provider was seeking to recover first-party no-fault benefits on behalf of an assignor from an insurance company. The insurance company argued that the assignor was injured during the course of his employment, and therefore workers' compensation benefits might be available. The main issue decided is whether the assignor was acting in the course of his employment at the time of the accident. The court held that the issue of whether the assignor was acting as an employee at the time of the accident must be resolved by the Workers' Compensation Board, and therefore, the matter is remitted to the Civil Court to be held in abeyance pending a determination by the Workers' Compensation Board.

The court considered an appeal in a case where Veraso Medical Supply Corp was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co. The main issue decided was whether the provider had failed to provide requested verification, and if the affidavit submitted by the provider was sufficient to give rise to a presumption that the verification had been provided. The court held that the affidavit submitted by the provider was sufficient to create a triable issue of fact as to whether the verification had been provided and therefore, reversed the order of the Civil Court and denied the defendant's motion seeking summary judgment dismissing the second cause of action.

The court considered a case in which Central Park Physical Medicine & Rehab, P.C. sought to recover assigned first-party no-fault benefits from IDS Property & Casualty Insurance Company. The main issue was whether the insurance company had established that it had timely mailed each of the examination under oath (EUO) scheduling letters to the medical provider. The holding of the court was that the insurance company had demonstrated that it had timely mailed the scheduling letters and that the medical provider had failed to appear for the scheduled EUOs. As a result, the court reversed the lower court's decision and granted the insurance company's motion for summary judgment dismissing the complaint. The decision was made on July 11, 2019.

The case involved a medical provider who sought to recover assigned first-party no-fault benefits from an insurance company. The insurance company requested the medical provider for examinations under oath, but the medical provider refused to appear for the requested examinations unless the insurer provided reasons for requesting the examinations. The insurance company filed a motion for summary judgment to dismiss the complaint on the ground that the medical provider failed to appear for the scheduled examinations under oath. However, the court found that there was no requirement in the regulations for the insurer to specify the reasons for requesting the examinations under oath. As a result, the court held that the insurance company was not required to provide the reasons for its demand for examinations under oath, and granted the motion for summary judgment, dismissing the complaint. In summary, the main issue considered in this case was whether the insurance company was obligated to provide reasons for requesting examinations under oath, and the holding of the court was that the insurance company was not required to do so, and therefore, the motion for summary judgment to dismiss the complaint was granted.

The main issue in this case was whether the medical services provided by the plaintiff were medically necessary. The court considered the claim forms, denial of claim forms, and the testimony of defendant's peer review doctor, who stated that the services lacked medical necessity. The plaintiff did not call any witnesses to rebut this testimony. The court found that the defendant sufficiently rebutted the presumption of medical necessity and that the plaintiff failed to meet its ultimate burden of proving, by a preponderance of the evidence, that the services at issue were medically necessary. As a result, the judgment that dismissed the second, third, fourth, sixth, and eighth causes of action was affirmed.

The relevant facts of the case were that the plaintiff, Valdan Acupuncture, P.C., sought to recover first-party no-fault benefits resulting from a Jan. 11, 2011 motor vehicle accident assigned to them by Joanne Watson Mack. However, the defendant, Nationwide Mutual Fire Ins. Co., had commenced a declaratory judgment action seeking a declaration that the accident was not covered by their insurance policy. The main issue decided was whether the plaintiff's action to recover benefits was barred based on the outcome of the declaratory judgment action. The court held that under the doctrine of res judicata, the final adjudication in the declaratory judgment action precluded the plaintiff from litigating their claim for benefits as they were in privity with the assignor and were charged with notice that their rights to the assignment were subject to the competing claim. Therefore, the order to grant the defendant's motion for summary judgment and dismiss the complaint was affirmed.

The court considered the fact that the defendant-insurer established its prima facie entitlement to summary judgment dismissing the underlying first-party no-fault claims as premature. The main issue decided was whether the plaintiff had fully responded to the defendant's requests for additional verification, and whether the then-applicable thirty-day period to pay or deny the claims had begun to run. The holding of the court was that since verification remained outstanding, the claims were not overdue, and plaintiff's action was premature. Therefore, the court reversed the order of the Civil Court and granted the defendant's motion for summary judgment, dismissing the complaint.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which denied the defendant's motion for summary judgment dismissing the complaint. The main issue decided was whether the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs) in an action by a provider to recover assigned first-party no-fault benefits. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted, as the affirmation from the doctor who was to perform the IMEs was sufficient to establish that the plaintiff's assignor had failed to appear for the scheduled IMEs. As plaintiff had not challenged the court's finding that the defendant was otherwise entitled to judgment, the order was reversed and the defendant's motion for summary judgment dismissing the complaint was granted.