No-Fault Case Law

The relevant facts the court considered were the failure of the plaintiff's assignor to appear for scheduled chiropractic independent medical examinations (IMEs) and the timely denial of the claim by the defendant insurance company. The main issues decided were whether the scheduling letters for the IMEs had been timely mailed and whether the plaintiff's assignor had failed to comply with a condition precedent to coverage. The holding of the court was that the defendant insurance company had established that the IME scheduling letters had been timely mailed and that the plaintiff's assignor had failed to appear for the scheduled IMEs, entitling the defendant to summary judgment dismissing the complaint. The court also declined to consider the plaintiff's remaining contentions and affirmed the order.

The relevant facts considered by the court were that a medical service provider was seeking first-party no-fault benefits from an automobile insurance company. The insurance company had reduced the amount billed for a specific code of medical services pursuant to the workers' compensation fee schedule. The main issue decided was whether the insurance company had properly applied the fee schedule and whether this defense was properly set forth in the denial of the claim form. The holding of the case was that the insurance company's affidavit was sufficient to demonstrate that the fee schedule was properly applied, and the denial of benefits referenced an attached "Explanation of Review," which supported the insurance company's defense. Therefore, the court affirmed the order granting the insurance company's motion for summary judgment and denying the medical service provider's cross motion for summary judgment.

The court considered the facts of a nonjury trial in which a provider was attempting to recover assigned first-party no-fault benefits. The sole witness at the trial was the plaintiff's third-party biller. The main issue decided was whether the witness was capable of establishing a business record foundation for the plaintiff's claim forms, which had been admitted into evidence. The court held that, pursuant to the holding in Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., the testimony of the plaintiff's witness was sufficient to establish the plaintiff's prima facie case. As the defendant failed to proffer a defense, the judgment in favor of the plaintiff was affirmed.

The main issue in this case was whether the provider, Health Needles Acupuncture, P.C., was entitled to recover assigned first-party no-fault benefits from the defendant, Allstate Insurance Company. The court considered the claim forms that had been mailed to and received by the defendant, and whether the defendant had failed to pay or deny the claim within the prescribed 30-day period. The court found that the plaintiff had established its entitlement to judgment as a matter of law based on the untimeliness of the denials. However, the defendant's affidavits described its standard mailing practices and procedures, establishing the timely mailing of the denial of claim forms and raising a triable issue of fact. As a result, the court affirmed the order denying plaintiff's motion for summary judgment.

The main issue in this case was whether the insurance company was entitled to summary judgment dismissing the portion of a claim for first-party no-fault benefits that was billed under code 97810, based on the provider's failure to respond to the insurer's verification requests. The court considered the fact that the single claim form involved two types of services, each billed under a separate code, and found that the insurer had established its defense as to one code, but not as to code 97810. The court held that a claim need not be paid or denied until all demanded verification is provided, and that a timely verification request tolls an insurer's time to pay or deny the entire claim. The insurer demonstrated that it had timely mailed initial and follow-up requests for verification and had not received the requested verification, so the court reversed the lower court's decision and granted the insurer's motion for summary judgment dismissing the claim billed under code 97810.

The court considered a case where a chiropractic center was attempting to recover no-fault benefits from an insurance company, and where the insurance company had denied these claims based on the plaintiff's assignor's failure to appear for scheduled independent medical examinations (IMEs). The main issue was whether the insurance company had timely and properly denied the claims based on the assignor's nonappearance for the IMEs. The court held that the chiropractor and doctor who were scheduled to perform the IMEs failed to demonstrate personal knowledge of the nonappearance of the assignor, and therefore the insurance company failed to establish its entitlement to the dismissal of the claims as a matter of law. The court ultimately modified the order to provide that the insurance company's cross motion seeking summary judgment on the third and fourth causes of action were denied.

The main issue in this case was whether the plaintiffs, Tutto Anesthesia, Palisade Surgery Center, and Neal Goldsmith, were entitled to partial summary judgment on their first-party no-fault claims against American Country Insurance Company. The court held that the plaintiffs had established their entitlement to partial summary judgment on their claims, as the defendant had failed to raise a triable issue in opposition. The court also found that the defendant had waived objections based on lack of proof of assignment and could not assert the defense of excessive fees, as it had not established that its denials were timely issued within the statutory 30-day period. The court further found that the defendant had failed to demonstrate that summary judgment was premature due to outstanding discovery, and rejected the defendant's speculative contention that further discovery may support its lack of coverage defense. Ultimately, the court reversed the lower court's order and granted the plaintiffs' cross motion for partial summary judgment, while denying the defendant's motion seeking to compel discovery.

The main issue in this case was whether the defendant-insurer was entitled to summary judgment dismissing the action seeking recovery of first-party no-fault benefits. The court considered evidence submitted by the defendant to show that it timely and properly mailed notices for independent medical examinations (IMEs) to the plaintiff's assignor and his counsel, and that the assignor failed to appear at the scheduled IMEs. The defendant made a prima facie showing of entitlement to summary judgment by submitting competent evidence of the assignor's nonappearance. In opposition, the plaintiff did not specifically deny the assignor's nonappearance or otherwise raise a triable issue with respect to the mailing or reasonableness of the underlying notices. Therefore, the court reversed the motion court's decision, granted the defendant's motion for summary judgment, and dismissed the complaint.

The court considered the defendant's appeal from an order of the Civil Court of the City of New York, Bronx County, which denied its motion for summary judgment dismissing the complaint. The main issue was whether the defendant had established its entitlement to summary judgment dismissing the complaint based on the plaintiff's alleged untimely submission of the claims beyond the applicable 45-day time limit. The court held that the defendant had failed to meet its burden as it did not establish its regular practices and procedures in retrieving, opening, and indexing its mail and in maintaining its files on existing claims. Therefore, the denial of the defendant's motion was required, regardless of the sufficiency of the plaintiff's opposition papers. As a result, the court affirmed the order of the Civil Court, denying the defendant's motion for summary judgment.

In this case, American Transit Insurance Company sought a declaration that Jaga Medical Services, P.C. and other defendants were not entitled to a no-fault benefits due to the claimant's failure to appear for scheduled examinations under oath (EUO). The defendants-appellants argued that it was the responsibility of the plaintiff to request the EUO and demonstrate that it was properly scheduled and timely. The court considered these arguments and determined that the reason for the EUO request was essential to justify the opposition to plaintiff's summary judgment motion, and that such fact was exclusively within the knowledge and control of the movant. Therefore, further discovery on the plaintiff's handling of the claim was necessary to determine whether the EUOs were timely and correctly requested. Consequently, the underlying motion for summary judgment was denied, and the judgment was vacated.