No-Fault Case Law

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.

In Matter of Zurich American Insurance, an arbitrator failed to give preclusive effect to the jury's determination that a certain individual did not sustain any injuries due to a car accident, thereby awarding the insurance company a sum upon that determination. Hereford Insurance Company appealed the order, but the Supreme Court, Queens County upheld the petition and the denial of the cross petition. According to the appellate division, the decision to not give preclusive effect to the jury verdict was irrational and arbitrary. Furthermore, it was decided that an insurance company, as a subrogee, stands in place of the subrogor, such that two companies are in "privity," allowing the company to be bound by the prior judgment in a case to which it was not originally party to. The stay was affirmed and the court also ordered that Hereford reimburse Zurich for its legal fees.

The case of Andrew Carothers, M.D., P.C. v Progressive Ins. Co. involved determining whether an insurer could withhold payments for medical services provided by a professional corporation when there was a "willful and material failure to abide by" licensing and incorporation statutes. The main issue was whether a finding of fraud was required for the insurer to withhold payments to a medical service corporation improperly controlled by nonphysicians. The court ultimately held that there was no requirement for fraudulent intent or conduct "tantamount to fraud" for the insurer to withhold payments to a medical service corporation improperly controlled by nonphysicians. The court considered Andrew Carothers, M.D., P.C., a professional service corporation, which was formed by a radiologist in partnership with a nonphysician, leading to exorbitant fees being charged to the corporation for MRI equipment. The corporation was controlled by nonphysicians, and the quality of patient care was minimal, leading to no payment by insurance companies and eventual closure of the corporation.

The main issue in this case was whether the limits of the Florida insurance policy had been exhausted prior to the insurer's receipt of the claims, and whether the provider was entitled to be paid for its services pursuant to the workers' compensation fee schedule. The court found that the insurer failed to establish with admissible evidence that Florida law applied and that the policy limits had been exhausted. Therefore, the court held that the branches of the insurer's cross motion seeking summary judgment dismissing the third, fifth and seventh causes of action were denied. However, the evidence submitted by the insurer demonstrated that the provider was not entitled to be paid for certain services pursuant to the workers' compensation fee schedule, and the court found that the provider failed to raise a triable issue of fact in opposition. As a result, the branches of the provider's motion seeking summary judgment on the third, fifth and seventh causes of action were properly denied.

The court considered whether proper service of process had been completed in an action by a provider to recover assigned first-party no-fault benefits. The main issue was whether the affidavit of service demonstrated that the summons and complaint were served properly, as required by CPLR 3215. The court determined that proof of proper service is a prerequisite for the entry of a default judgment, and because the record did not demonstrate that an acknowledgment of receipt had been subscribed and affirmed by the defendant, the court reversed the judgment, vacated the order, denied the plaintiff's motion for the entry of a default judgment, granted the defendant's cross-motion to dismiss the action, and remitted the matter to the Civil Court for the entry of a judgment in favor of the defendant dismissing the action without prejudice. Therefore, the holding of the case was in favor of the defendant, and the action was dismissed without prejudice.

The court considered the appeal from an order of the Civil Court denying the defendant's motion seeking summary judgment dismissing part of the complaint and granting the plaintiff's cross-motion seeking summary judgment on that portion of the complaint. The main issue was whether the defendant's proof was sufficient to establish the proper mailing of examination under oath (EUO) scheduling letters and whether the plaintiff had submitted sufficient evidence to establish its entitlement to summary judgment. The court held that the defendant had established the proper mailing of the EUO scheduling letters, but failed to show that the plaintiff's claims were not timely denied. The court also held that the plaintiff failed to demonstrate its prima facie entitlement to summary judgment. As a result, the order was modified to deny the branch of the plaintiff's cross-motion seeking summary judgment on the claims as assignee of Rhonda Cobin.