No-Fault Case Law

The court considered the fact that Oleg's Acupuncture, P.C. sought unpaid first-party no-fault benefits for services rendered between May 7, 2014, and July 16, 2014. The main issue decided was whether defendant Hereford Insurance Co. was required to establish that it had timely denied the claims in order to preserve its fee schedule defense. The court found that, under 11 NYCRR 65-3.8 (g) (1) (ii); (2), no payment was due for claimed medical services that exceeded the charges permissible under Insurance Law sections 5108 (a) and (b) and the regulations promulgated thereunder for services rendered by medical providers. The holding of the court was that defendant was not required to establish that it had timely denied the claims in order to preserve its fee schedule defense, and therefore, the judgment was reversed, plaintiff's motion for summary judgment was denied, and defendant's cross-motion for summary judgment dismissing the complaint was granted.

The court considered the appeal from an order granting the defendant's motion for summary judgment and denying the plaintiff's cross motion for summary judgment. The case involved an action seeking recovery of assigned first-party no-fault benefits. The main issue decided was that the action was not ripe for summary disposition, as the proof submitted by the defendant was insufficient to establish that the amounts charged by the plaintiff for the services provided exceeded the rates set forth in the fee schedule. The holding of the court was that the defendant's motion for summary judgment was denied and the complaint was reinstated, as the new arguments raised in the defendant's reply papers failed to eliminate all triable issues of fact and revealed additional matters in dispute.

The main issue in the case was whether the defendant, Hereford Insurance Company, was required to pay the plaintiff, Precious Acupuncture Care, P.C., for medical services rendered between December 2013 and April 2014. The defendant argued that the plaintiff sought to recover amounts exceeding the workers' compensation fee schedule, and supported their argument with an affidavit by a certified medical coder and biller. The plaintiff moved for summary judgment, and the defendant cross-moved for summary judgment dismissing the complaint. The court held that the defendant was not required to establish that it had timely denied the claims in order to preserve its fee schedule defense, as the services were provided between December 2013 and April 2014. As a result, the court reversed the judgment, vacated the order, denied the plaintiff's motion for summary judgment, and granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered a dispute between One To One Rehab PT, P.C. and Allstate Insurance Company over the recovery of assigned first-party no-fault benefits. Plaintiff moved for summary judgment, but defendant submitted an affidavit from an employee stating that there was no coverage by defendant for the vehicle in question on the date of the accident. The court found that the defendant's affidavit was sufficient to demonstrate that plaintiff's claims did not arise out of a covered incident. As the plaintiff failed to raise a triable issue of fact in opposition to defendant's cross motion, the Civil Court properly denied plaintiff's motion for summary judgment and granted defendant's cross motion for summary judgment dismissing the complaint. The main issue decided was whether the defendant provided insurance coverage for the vehicle in question on the date of the accident. The holding was that the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment dismissing the complaint was affirmed.

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits from an accident that occurred on April 19, 2010. The defendant argued that the action was barred by the doctrine of res judicata based on a previous court order. The main issue decided was whether the prior court order had collateral estoppel effect and whether the subsequent order corrected the date of the accident. The holding of the case was that the April 3, 2013 court order did not have res judicata effect as it was vacated by a subsequent order. The court also held that the subsequent order, which corrected the accident date, was a conclusive final determination, and res judicata applied. The court affirmed the previous order granting the defendant's cross motion for summary judgment.

The main issue in this case was whether the defendant, Auto One Ins. Co., had grounds sufficient to set aside a stipulation that they had entered into with the plaintiff, Zayas Physical Therapy, P.C. The defendant had failed to submit written opposition to the plaintiff's motion for summary judgment, and as a result, the Civil Court had granted the motion upon the consent of both parties and entered a judgment in favor of the plaintiff. The defendant then moved to vacate the order and judgment, arguing that they had a reasonable excuse for their default and a meritorious defense to the action. However, the Civil Court denied the defendant's motion on the ground that they had failed to offer a reasonable excuse for their failure to submit written opposition to the plaintiff's motion for summary judgment. The Appellate Term, Second Department affirmed the decision, holding that the defendant had failed to make a sufficient showing to set aside the stipulation and judgment.

The main issue in this case was whether the testimony of the defendant's expert medical witness, who was not the expert who had prepared the peer review report upon which the defendant's denial of the plaintiff's claim form was based, should have been permitted in a nonjury trial held to determine the lack of medical necessity of the supplies at issue. The defendant's notice of appeal from the decision to preclude the testimony of the expert witness was deemed a notice of appeal from the judgment entered. The court held that the defendant's expert medical witness should have been permitted to testify as to her opinion on the lack of medical necessity of the supplies at issue, limited to the basis for the denial as set forth in the original peer review report. Therefore, the judgment was reversed and the matter was remitted to the Civil Court for a new trial.

The main issue decided in this case was whether the $50,000 policy limit of the insurance policy had been exhausted before the petitioner became obligated to pay the respondent's claim for unpaid no-fault benefits. The court held that when an insurer has paid the full monetary limits set forth in the policy, its duties under the contract of insurance cease. The court also determined that a defense that the coverage limits of the policy have been exhausted may be asserted by an insurer despite its failure to issue a denial of the claim within the 30-day period. The court found that the petitioner-insurer's submissions raised triable issues as to whether the $50,000 policy limit had been exhausted by payments of no fault benefits to the respondent and other providers, and remanded the matter to Civil Court for a framed issue hearing on that issue.

The court considered an appeal from an order of the Civil Court of the City of New York, Queens County, which denied the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment. The main issue was whether the plaintiff was entitled to recover $2,361.87 in first-party no-fault benefits, and whether the defendant's defense that the amounts sought to recover were in excess of the workers' compensation fee schedule was valid. The holding of the case was that the defendant did not sufficiently demonstrate that the denial of claim form had been timely mailed, and therefore was not entitled to summary judgment dismissing the portion of the complaint seeking to recover the sum of $2,361.87. As a result, the order was modified to deny the branch of the defendant's cross motion seeking summary judgment dismissing that portion of the complaint.

The court considered the fact that the plaintiff, a medical supply company, was seeking to recover assigned first-party no-fault benefits from the defendant, an insurance company. The main issue decided was whether the plaintiff had failed to appear for duly scheduled examinations under oath (EUOs) as required. The holding of the court was that the defendant's proof sufficiently established proper mailing of the EUO scheduling letters and that the plaintiff had indeed failed to appear for the scheduled EUOs. As a result, the court affirmed the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint.