No-Fault Case Law

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.

The main issue in this case was whether the collisions involving insured motor vehicles were intentional acts, and whether the insurance carriers had a duty to pay no-fault claims relating to those collisions. The trial court had declared that the collisions were intentional acts, and that the insurance carriers were not obligated to pay related no-fault claims. The appellate court affirmed the trial court's decision, holding that the insurance carriers demonstrated their prima facie entitlement to judgment as a matter of law by providing evidence that the collisions were intentional, including evidence that the insured individuals procured the insurance policies fraudulently and that the collisions occurred under similar circumstances. The appellate court also found that the appellants failed to raise a triable issue of fact or to establish that the plaintiffs' evidence was inadmissible, and therefore the trial court properly granted the summary judgment in favor of the insurance carriers.

The court considered a case where plaintiff Horizon P.T. Care, P.C. was seeking to recover assigned first-party no-fault benefits from defendant State Farm Mutual Automobile Ins. Co. for services rendered to an assignor injured in a motor vehicle accident. State Farm claimed that Horizon had failed to appear for scheduled examinations under oath and that certain causes of action were barred by a previous declaratory judgment. The main issue was whether Horizon was entitled to recover the benefits and if the causes of action were barred by res judicata. The court held that Horizon's failure to appear for examinations under oath barred certain causes of action, and that the remaining causes of action were also properly dismissed as State Farm's employees' affidavits gave rise to a presumption that the necessary documents had been timely mailed. Therefore, the order denying Horizon's motion for summary judgment and granting State Farm's cross motion for summary judgment dismissing the complaint was affirmed.

The court considered a motion for summary judgment related to a claim for assigned first-party no fault benefits resulting from medical treatment provided to an individual after a motor vehicle accident. The main issue decided was whether the defendant was entitled to summary judgment and dismissal of the complaint based on the plaintiff's failure to attend scheduled Examinations Under Oath (EUOs). The holding of the court was that the defendant's motion for summary judgment was granted, as the plaintiff failed to rebut the presumption of the mailing of the EUO scheduling letters and non-appearance at the EUOs. The plaintiff's cross-motions for summary judgment were denied, and the matter was dismissed. The court found that the defendant had established timely mailing of EUO scheduling letters and the non-appearance of the assignor at scheduled EUOs, and the plaintiff had failed to raise an issue of fact for trial.

The court considered a motion for summary judgment by the defendant, who sought to dismiss the complaint on the grounds that the plaintiff failed to appear for scheduled examinations under oath (EUOs). The main issue was determining whether the defendant's denials of the claims for services rendered were timely based on the plaintiff's nonappearance at the duly scheduled EUOs. The court held that there was an issue of fact as to whether an EUO scheduled between certain dates was mutually rescheduled, and therefore, the defendant's entitlement to summary judgment was dependent upon whether the plaintiff's nonappearance at a scheduled EUO occurred on a specific date. The court ultimately affirmed the order, insofar as appealed from, and held that the branch of the defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims for services rendered was properly denied.