No-Fault Case Law

The court considered the fact that the defendant-insurer failed to establish its entitlement to summary judgment dismissing the underlying first-party no-fault action based upon plaintiff's alleged failure to provide proof of claim. The defendant's claim specialist asserted that they had "no record of receiving" the claim, which was allegedly improperly mailed to a Florida post office box where the defendant "never accepted mail." However, the court found these assertions to be vague and conclusory, and that the defendant failed to make a prima facie showing that the claim was not properly and timely submitted. The main issue decided was whether the defendant had met its burden in proving that the claim was not properly submitted, and the court determined that they had not. The holding of the case was that the defendant's motion for summary judgment was denied, and the complaint was reinstated.

The court considered a case about a medical provider seeking payment under a first-party no-fault benefits assignment. The defendant denied the claim in part because the plaintiff did not bill the services in accordance with the applicable fee schedule. Both parties moved for summary judgment. The main issue decided was whether the "report" in a "By Report" claim is an additional form of documentation or an integral part of the bill or claim form. The court held that the report is a necessary component of the bill for a "By Report" claim, and its absence renders the claim form incomplete, failing to satisfy the prima facie requirements laid out in Viviane Etienne, and therefore failing to trigger the insurer's obligation to timely pay or deny the claim. Therefore, plaintiff's motion to renew and reargue was denied.

The main issues in this case were whether the defendant had a reasonable excuse for its delay in serving an answer and whether the defendant had a meritorious defense to the action. The court found that the defendant had established a reasonable excuse for its failure to serve an answer and had made a prima facie showing of a viable defense based on a lack of medical necessity. As a result, the court reversed the order, denying the plaintiff's motion to enter a default judgment and granting the defendant's cross motion to open its default in answering and to compel the plaintiff to accept a late answer. Therefore, the holding of the case was in favor of the defendant, and the plaintiff's motion was denied while the defendant's cross motion was granted.

The court considered the fact that the defendant had moved for summary judgement to dismiss a complaint by a provider seeking to recover assigned first-party no-fault benefits, on the basis that the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The Civil Court had denied the defendant's motion, but made findings that the denial of claim form had been timely and proper, and that the sole issue for trial was whether the plaintiff's assignor had failed to appear for the scheduled IMEs. The main issue decided was whether the plaintiff's assignor had failed to appear for the scheduled IMEs, and the holding of the appellate term was that the defendant's motion for summary judgment was granted, reversing the order of the Civil Court. The court found that the affirmation submitted by 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, and as the plaintiff had not challenged the finding that the defendant was otherwise entitled to judgement, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the appeal from an order of the Civil Court of the City of New York, Queens County, which granted the defendant's motion for summary judgment dismissing the second through seventh causes of action in a case where a provider sought to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff's assignor had failed to appear for duly scheduled examinations under oath. The court affirmed the order, holding that the plaintiff's assignor had indeed failed to appear for the scheduled examinations under oath, and therefore, the defendant's motion for summary judgment was granted. The decision was consistent with a previous case, Greenway Med. Supply Corp., as Assignee of Tellechea Maria v Travelers Ins. Co., which was decided at the same time and provided similar grounds for affirming the lower court's decision.

The case involves Radiology Today, P.C. suing Geico Ins. Co. to recover assigned first-party no-fault benefits for services provided to its assignor. The main issue was whether the peer review report could be admitted into evidence at trial to prove the insurer's defense of lack of medical necessity. The court held that an insurer cannot use a peer review report at trial for its "truth" to prove the defense and that this would be impermissible bolstering of the expert's testimony. The court directed a verdict in favor of plaintiff, but the Appellate Term reversed and remitted the matter for a new trial on the first cause of action, indicating that a new trial is required to determine whether the services at issue were medically necessary.

The relevant facts considered by the court were that Greenway Medical Supply Corp. was seeking to recover first-party no-fault benefits as an assignee of Castillo Teofilo from Travelers Insurance Company. The issue decided was whether the lower court had erred in granting the defendant's motion for summary judgment dismissing the complaint on the grounds that the plaintiff had failed to appear for scheduled examinations under oath. The holding of the case was that the lower court's decision to grant the defendant's motion for summary judgment was affirmed, and the plaintiff's complaint was dismissed. The court based its decision on a similar case involving the same plaintiff and defendant, wherein it reached the same conclusion.

The court considered whether the provider had failed to appear for scheduled examinations under oath (EUOs) and whether the denial of claim form had been timely mailed. The main issue was whether the provider had failed to appear for the EUOs as required, and whether the denial of claim form had been timely mailed. The court held that the provider had failed to appear for the EUOs, as evidenced by the affirmation submitted by the defendant's attorney. The court also held that the denial of claim form had been timely mailed, as established by the affidavits submitted by the defendant. As a result, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The court considered the fact that the plaintiff, Charles Deng Acupuncture, P.C., was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co. The main issue decided was whether the plaintiff had failed to appear for duly scheduled examinations under oath (EUOs) as required by the insurance company. The court held that the affirmation submitted by defendant's attorney was sufficient to establish that the plaintiff had indeed failed to appear for the EUOs. The court also found that the plaintiff's attempt to reschedule the EUOs was not valid, as the person called and the phone number used did not match the information provided by the insurance company's EUO scheduling letter. Therefore, the court affirmed the order granting defendant's motion for summary judgment dismissing the complaint.

The court considered a case involving a provider seeking to recover assigned first-party no-fault benefits in the amount of $3,748.69 for services rendered. The defendant denied the claim in full on September 11, 2012, but subsequently paid the sum of $256.34 on December 13, 2012. The defendant admitted that it should have paid the plaintiff $267.79 and agreed to pay the difference of $11.45 with appropriate interest. The main issue decided was whether the defendant demonstrated that the sum of $267.79 would fully compensate the plaintiff for the services in accordance with the workers' compensation fee schedule. The holding of the court was that the defendant's cross motion should have been denied, but the plaintiff failed to establish its prima facie entitlement to summary judgment on any amount in excess of $11.45. Therefore, the judgment was reversed, the order granting the defendant's cross motion was vacated, and the defendant's cross motion was denied.