No-Fault Case Law

The relevant facts the court considered were that the defendant-insurer timely and properly mailed notices for examinations under oath (EUOs) to the plaintiff's assignor, and the assignor failed to appear at two scheduled EUOs. The main issue decided was whether the insurer was entitled to summary judgment dismissing the action for first-party no-fault benefits. The holding of the case was that the defendant-insurer made a prima facie showing of entitlement to summary judgment by establishing the timely and proper mailing of the EUO notices, and the plaintiff did not raise a triable issue with respect to the assignor's nonappearance at the scheduled EUOs. Therefore, the appellate court reversed the order of the lower court and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the defendant-insurer's motion for summary judgment dismissing a first-party no-fault action. The main issue decided was whether the peer review report provided by the defendant's acupuncturist was sufficient to establish that the services rendered were not medically necessary. The court held that while the defendant's documentary submissions were sufficient to establish the timely and properly mailed denial of claim forms, the peer review report failed to make a prima facie showing that the services rendered were not medically necessary. As a result, the court reversed the order of the Civil Court, denied the defendant's motion, and reinstated the complaint.

The court considered the fact that defendant's documentary submissions failed to eliminate all triable issues as to whether it properly denied plaintiff's no-fault claim for $54.74, billed under CPT code 99203. The main issues decided in this case were whether the plaintiff's claim for first-party no-fault benefits billed under CPT code 99302 should be reinstated, and whether the Civil Court properly exercised its discretion to allow the defendant to correct the defect in the form of the IME report of its acupuncturist/chiropractor. The holding of the case was that the order was modified by reinstating plaintiff's claim for first-party no-fault benefits billed under CPT code 99302, and as modified, the order was affirmed.

The court considered the appeal by a New York City provider to recover first-party no-fault benefits for services rendered to its assignor, who allegedly sustained injuries in a New York City motor vehicle accident. The main issues were whether personal jurisdiction over the defendant had been acquired, whether a conflict-of-law analysis required the application of Michigan law, and whether there was a lack of coverage for the vehicle involved in the accident. The holding of the court was that the service of process upon the Superintendent of Insurance established jurisdiction over the defendant, and the Michigan law could not be relied on to withhold payment of no-fault benefits to the plaintiff for the medical services it rendered to its assignor, who was an innocent third party. The court reversed the previous decision, denied the branch of the defendant's motion seeking summary judgment dismissing the complaint on the ground of lack of insurance coverage, and remitted the matter to the Civil Court for a determination of the remaining issue.

The case involved a dispute over first-party no-fault benefits for medical services rendered to Cosby Reavis. The plaintiff submitted a claim form and invoice to the defendant for services related to three different codes under the Official New York Workers' Compensation Medical Fee Schedule. The defendant denied the claim based on a defense of lack of medical necessity and not billing services correctly. The court decided that the plaintiff failed to meet its burden for services related to code 20999 due to insufficient information provided for the amount charged for the services. However, the court granted the plaintiff's motion for summary judgment with regard to services related to codes 20553 and 99215, and the defendant's motion was granted with respect to services billed under code 20999. Therefore, the plaintiff was awarded $267.79 for the services related to codes 20553 and 99215, plus costs, fees, disbursements, and interest.

The case involved an appeal from an order of the Civil Court of the City of New York denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint. The main issue was whether the defendant, American Commerce Insurance Company, had properly paid the first-party no-fault benefits under a Massachusetts insurance policy. The court found that Massachusetts law applied to the substantive issues and that the defendant had made a prima facie showing that it had properly paid the medical expenses coverage as provided in the insurance policy. The court also found that the plaintiff failed to raise a triable issue of fact in opposition and that its remaining arguments were without merit. As a result, the order was affirmed, and the appellate court held in favor of the defendant, American Commerce Insurance Company.

The relevant facts considered in this case were that Beal-Medea Products, Inc., as the assignee of Shachar Blau, was seeking to recover assigned first-party no-fault benefits from Geico General Insurance Co. During the trial, the Civil Court denied plaintiff's repeated attempts to have its purported assignment of benefits admitted into evidence. Ultimately, defendant's oral motion for judgment pursuant to CPLR 4401 was granted, and the complaint was dismissed. The main issue decided was whether the denial of plaintiff's repeated attempts to admit the assignment of benefits into evidence was a valid reason for granting defendant's oral motion to dismiss the complaint. The holding of the court was that defendant's CPLR 4401 motion was premature as it was made before the close of plaintiff's case, and the court's reason for granting the application was erroneous. The court ruled that a no-fault plaintiff is not required to submit an executed assignment of benefits to establish a prima facie case, and the matter was remitted to the Civil Court for a new trial.

The court considered the facts of a case involving a dispute over first-party no-fault benefits, where the plaintiff had previously moved to restore the case after it had been marked off in 1999 and faced a notice to restore in 2010. The main issue decided was whether the plaintiff had demonstrated a meritorious cause of action and a reasonable excuse for the delay in moving to restore the case. The court held that the plaintiff had failed to demonstrate a meritorious cause of action or reasonable excuse for the multi-year delay, and that the Civil Court had properly adhered to its prior determination. Additionally, the court held that the Civil Court properly granted the defendant's cross motion to dismiss the complaint pursuant to CPLR 3216 (e) based on relevant case law. The Appellate Term affirmed the order, concluding that the Civil Court's decision was proper.

The case of Government Employees Insurance Co. v Avanguard Medical Group, PLLC involved a dispute over whether a no-fault insurance carrier was required to pay an office-based surgery (OBS) center for the use of its physical location and related support services. Avanguard Medical Group, PLLC, which is accredited under New York's Public Health Law as an OBS facility, argued that Insurance Law § 5102 required payment for OBS facility fees. The insurance carriers, on the other hand, argued that neither the statute nor regulatory frameworks mandated payment for OBS facility fees. The main issue in the case was whether the no-fault insurance carrier was legally obligated to reimburse Avanguard for OBS facility fees. The Court of Appeals held that the no-fault insurance carrier was not required to reimburse Avanguard for OBS facility fees, as neither the statutory nor regulatory frameworks mandated such payments. This holding was based on the fact that the fee schedules provided reimbursement for professional services delivered in an OBS setting, but did not expressly permit reimbursement for OBS facility fees. The court also noted that the absence of language regarding OBS facility fees in the regulations for hospitals and ambulatory surgery centers suggested that OBS facility fees were not intended to be reimbursed. The court emphasized that the legislature capped total payments for basic economic loss and delegated the determination of fee rates to the Chair and the Superintendent, neither of whom had chosen to include OBS facility fees in the regulatory schedules. Therefore, the court affirmed the Appellate Division's decision that the insurance carrier was not required to reimburse Avanguard for OBS facility fees.

The main issue in this case was whether the petitioner, American Independent Insurance Co. (AIIC), should be allowed to permanently stay arbitration of claims for no-fault benefits under Insurance Law. The Supreme Court had previously determined that the claims were subject to arbitration, but AIIC claimed that it should not have to arbitrate because its policies did not contain an agreement to arbitrate. The court held that AIIC could not be estopped from raising these arguments, as the previous proceeding only concerned personal jurisdiction. Additionally, the court found that the obligation to arbitrate is not found in the policies but is instead imposed by the No-Fault Law. Since AIIC did not have authorization to do business in New York, the insurance company's policies could only satisfy the state's financial security requirements and provide first-party benefits if it was determined that AIIC controlled, was controlled by, or was under common control by, or was with an authorized insurer. As there was insufficient evidence to make that determination, the case was remitted to the Supreme Court for further hearing and a new determination.