No-Fault Case Law

The court considered the insurance company's petition to vacate an arbitration award in favor of the medical company. The insurance company demonstrated that the claimant failed to appear for an independent medical examination, which constituted a breach of a condition precedent vitiating coverage. The court held that the insurance company was entitled to judgment as a matter of law based on evidence of the claimant's failure to appear and established case law. Therefore, the arbitration award was vacated, and the medical company's request for attorney fees was denied, as their claim was deemed invalid as a matter of law.

The main issue decided in this case was whether a health service provider seeking No-Fault insurance compensation for providing post-surgery services had to establish that a prior arbitration award was affirmed by a master arbitrator, confirmed by a court, and not subject to de novo review as a prerequisite to arguing that the award constituted collateral estoppel on the issue of medical necessity for the surgery. The court held that the health service provider did not have to establish that the prior arbitration award was affirmed by a master arbitrator and confirmed by a court in order to argue that the award constituted collateral estoppel on the issue of medical necessity for the surgery. Following the arbitration award of Richard B. Ancowitz, Esq., the court granted Respondent U.S. Med Supply Corp.'s claim for No-Fault insurance compensation for post-surgery medical supplies provided or rented, and the judgment was in favor of the respondent. U.S. Med was awarded $4,000.00 for the services provided to Mahendra Singh, who claimed to have been injured in a motor vehicle accident and assigned his No-Fault insurance benefits to U.S. Med.

The court considered the facts surrounding a No-Fault insurance dispute, where an arbitrator awarded the respondent $2,450.73 for health service expenses following a motor vehicle accident. The petitioner insurance company originally denied the claim on the grounds that the injured party was acting within the course of employment and should have submitted the bills to a Workers' Compensation insurer. However, a Workers' Compensation Board later found that the injured party was not working at the time of the accident. The primary issue was whether the insurer could assert a defense of lack of medical necessity in a subsequent denial after the initial denial on different grounds had been overturned. The court decided whether the defense of lack of medical necessity, asserted after the initial denial based on employment status, should be considered in the arbitration process. The petitioner sought to vacate the arbitration award, arguing the defense of medical necessity had not been adequately addressed. The respondent cross-petitioned for confirmation of the arbitration award and sought additional costs and fees. The holding of the court was that the initial defense regarding the injured party's employment status did not preclude the insurer from later asserting a defense of lack of medical necessity. The court investigated whether the second defense was raised timely and whether it was considered during the arbitration process. Ultimately, the court denied the petition to vacate the master arbitration award, and granted additional attorney fees to respondent.

The main issues in this case were whether the court should review a verified petition to determine if it makes out a prima facie case when submitted by an insurance company to vacate awards of a No-Fault insurance hearing arbitrator and a master arbitrator in favor of a health service provider, and whether a No-Fault insurer makes out a prima facie case to vacate an arbitration award when no defense of lack of medical necessity was asserted in its denials of claim. The background of the case involved American Transit Insurance Company seeking to vacate a No-Fault Insurance master arbitration award in favor of Ortho City Services Inc.'s claim for No-Fault insurance compensation for medical supplies following a motor vehicle accident. The court found that the insurance company made out a prima facie case in support of vacatur of the arbitration award, and that the arbitrator erred with respect to an issue of medical necessity. Therefore, it was held that the petition to vacate the arbitration award should be granted.

The court considered the facts of a special proceeding commenced by an insurance company seeking an order and judgment vacating a No-Fault insurance master arbitration award in favor of a health service provider. The insurance company was seeking to vacate the awards of a No-Fault insurance hearing arbitrator and a master arbitrator in favor of the health service provider. The main issue decided was whether the insurance company made out a prima facie case for entitlement to vacatur where the bases for relief were not presented to either the hearing arbitrator or the master arbitrator. The court held that the insurance company did not make out a prima facie case for entitlement to vacatur, and therefore denied the petition to vacate the arbitration award in favor of the health service provider.

The main issue considered in the case was whether a defense of lack of medical necessity asserted in a second, subsequent denial of claim should be considered after a No-Fault insurer initially denied payment of bills on the grounds that the injured person was acting in the course of employment while driving and, therefore, the bills should be submitted to the Workers' Compensation insurer instead. American Transit Insurance Company ("ATIC") sought to vacate a No-Fault insurance master arbitration award which granted Nexray Medical Imaging PC's ("Nexray") claim for No-Fault insurance compensation for health service expenses. Nexray opposed the petition to vacate the master arbitration award and cross-petitioned for a judgment confirming the master arbitration award. The court held that the defense of lack of medical necessity should be considered, and vacated the arbitration award in favor of Nexray.

The relevant facts of the case were that the defendant, Allstate Insurance Company, appealed from a judgment awarding the plaintiff, James J. Kim, L.A.C., P.C., the principal sum of $2,018.77 after a nonjury trial to recover assigned first-party no-fault benefits. The main issue decided was whether the services in question were medically necessary. The court held that in a no-fault trial involving a defense of lack of medical necessity, the insurer had an initial burden to rebut the presumption of medical necessity, but it was ultimately the plaintiff who had the burden of proving, by a preponderance of the evidence, that the services were medically necessary. The Appellate Term, Second Department affirmed the judgment, stating that the record supported the determination of the Civil Court, and based upon its assessment of the credibility of the expert witnesses and the proof adduced at trial, the plaintiff sufficiently established by a preponderance of the evidence that the services at issue were medically necessary.

The court considered whether a No-Fault arbitration award was valid when the insurer denied payment due to unproven allegations and if there was a lack of evidence submitted to support the defense. The court also addressed if it was the role of a No-Fault hearing arbitrator to seek out the testimony from an examination under oath. The main issues decided were whether an insurer had the right to deny payment, and if a hearing arbitrator was responsible for finding specific testimony and evidence. The holding of the court was that the No-Fault arbitration award was vacated due to the lack of evidence to support the defense by the insurer, and that it is not the responsibility of the arbitrator to locate specific testimonies in the absence of the insurer's evidence.

The relevant facts that the court considered were that the plaintiff, a medical provider, brought an action against the defendant insurer for no-fault benefits owed for medical services provided to the insured. The defendant moved for summary judgment, as the insured assignor had not appeared at three scheduled examinations under oath, which they believed excused them from paying no-fault benefits. The plaintiff cross-moved for summary judgment on the complaint. The main issue decided was whether the defendant insurer was obligated to pay the no-fault benefits to the plaintiff, even though the insured assignor failed to appear at scheduled exams under oath. The holding of the case was that the defendant insurer was not obligated to pay the no-fault benefits to the plaintiff, as the letters scheduling the exams were timely and properly mailed, the insured failed to appear at the scheduled exams, and the defendant timely and properly followed up, ultimately leading to a proper denial of the claims when the insured failed to appear at the last scheduled exam under oath. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted, and the plaintiff's cross-motion for summary judgment on the complaint was denied.

The relevant facts considered by the court were a dispute between Pak Hong Sik MD Med. Care, P.C. (the plaintiff) and Omni Insurance Company (the defendant) over first-party No-Fault benefits for medical treatment provided to Jose Feliciano. The main issues decided by the court were the lack of personal jurisdiction of the defendant and whether the defendant was in default for failing to file an answer within 30 days from the court's prior order. The holding of the court was to deny the defendant's motion to dismiss the matter on the grounds of lack of personal jurisdiction, to require the defendant to file and serve its Answer within 14 days, and to deny the plaintiff's cross-motion while allowing them to renew it if the defendant failed to timely file its Answer. The court also emphasized that the defendant is barred from bringing any further pre-answer motions to dismiss.