No-Fault Case Law

The plaintiff appealed from an order of the Supreme Court in an action to recover no-fault medical benefits under an insurance contract, which granted the defendant's motion to vacate a clerk's judgment entered in favor of the plaintiff and against the defendant. The defendant sought to vacate a default in answering or appearing by demonstrating a reasonable excuse for the default and a potentially meritorious defense to the action. The defendant established a reasonable excuse through an employee's affidavit and attested to a clerical oversight regarding the delay in forwarding the summons with notice to its attorney. The defendant also demonstrated a potentially meritorious defense to the action. The Supreme Court exercised its discretion in granting the defendant's motion to vacate the default judgment, to extend its time to appear, and to compel the plaintiff to accept its late notice of appearance. Therefore, the order was affirmed.

The court considered the case of Epic Pain Management & Anesthesia Consultants, LLC appealing an order granting New York Central Mutual Fire Ins. Co.'s motion for summary judgment to dismiss the complaint. The main issue decided was whether the action seeking recovery of assigned first-party no-fault benefits arising from a series of epidural injections administered in Hackensack, New Jersey, was ripe for summary dismissal. The court held that the action was not ripe for summary dismissal as the defendant failed to address or refute the applicability of Insurance Department regulation (11 NYCRR) § 68.6, which provides that the permissible charge for a reimbursable health service performed outside New York State shall be the prevailing fee in the geographic location of the provider. The court reversed the order, denied the motion, and reinstated the complaint, finding that genuine triable issues were created by the defendant's arguments.

The case involved an action to recover first-party no-fault benefits. The issue before the court was whether the no-fault carrier could request a medical provider submit to an examination under oath (EUO) after previously denying all further no-fault benefits based on an independent medical examination (IME). Cecilio Pablo-Rodriguez, the eligible injured party, had his treatment for a motor vehicle accident injury denied by Allstate Insurance Company on the grounds of failing to appear for an EUO. However, Rodriguez's attorney had timely objected to Rodriguez being produced for an EUO. The court held that Allstate had not provided an objective basis for requesting Rodriguez appear for an EUO after the objection, therefore denying Allstate's motion for summary judgment. The main issues decided were whether Allstate had an objective basis for requesting an EUO after Rodriguez's attorney's timely objection, and whether the carrier could request an EUO after denying no-fault benefits based upon an IME. The court held that when the party who is requested to appear for an EUO timely objects to appearing for the EUO, the carrier must establish it had an objective standard for requesting the EUO, and that a carrier, even after denying no-fault benefits based on an IME, can request an EUO of the eligible injured party if the party continues to receive medical treatment and the provider continues to submit the no-fault claims for payment.

The court considered the defendant-insurer's motion to dismiss the complaint unless the plaintiff complied with the notice of deposition. The main issue decided was whether the defendant was entitled to depositions relating to its excessive treatment and fee schedule defenses, in light of the fact that it did not demonstrate entitlement to those depositions by timely denying the plaintiff's first-party no-fault claim. The court ultimately held that the defendant-insurer failed to demonstrate entitlement to the depositions and reversed the order, denying the defendant's motion. As a result, the defendant's motion to dismiss the complaint was also denied by the court.

The main issue decided in this case was whether the action was barred under the doctrine of res judicata and whether the plaintiff failed to establish its prima facie entitlement to summary judgement. The court considered the fact that the defendant had timely mailed EUO scheduling letters to the assignor and that the assignor had failed to appear for scheduled EUOs. The court also considered the Supreme Court's declaratory judgment, which found in favor of the defendant, American Transit. The holding of the case was that the action was indeed barred under the doctrine of res judicata, and the court affirmed the order of the Civil Court, which had granted the defendant summary judgment dismissing the complaint with prejudice.

The court considered the fact that the plaintiff, Delta Diagnostic Radiology, P.C., was seeking to recover no-fault benefits as an assignee of Jean Brouard. The main issue decided was whether there was fraudulent procurement of the insurance policy in question, as the defendant, National Liability & Fire Insurance Co., alleged that Brouard had misrepresented his place of residence. The court held that there was a triable issue of fact as to whether Brouard had provided a fraudulent address when obtaining the insurance policy, and thus, plaintiff's motion for summary judgment was denied. Additionally, the court found that the defendant failed to make a prima facie showing of entitlement to judgment dismissing the complaint as a matter of law. Therefore, the order was modified to provide that plaintiff's motion for summary judgment was denied.

The court considered the fact that Ultimate Health Products, Inc. had initiated a lawsuit to recover assigned first-party no-fault benefits for supplies provided to an individual who was injured in a motor vehicle accident. American Transit Insurance Company had also initiated a separate lawsuit, alleging that the injured individual had breached the insurance policy terms. In the end, the Supreme Court determined that the injured individual was not eligible for no-fault benefits and American Transit was not obligated to pay any claims for first-party no-fault benefits. The main issue was whether the present action was barred under the doctrine of res judicata, and the court held that it was, as any judgment in favor of the plaintiff in this action would destroy or impair rights or interests established by the Supreme Court declaratory judgment. Therefore, the court affirmed the order to dismiss the complaint.

The court considered whether the defendant's law firm should be disqualified in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant submitted sufficient proof to show that the plaintiff had failed to appear for scheduled examinations under oath, and whether the law firm representing defendant should be disqualified based on the attorney/witness rule. The holding of the case was that the defendant had submitted sufficient proof to show that the plaintiff had failed to appear for scheduled examinations under oath, and that the law firm representing the defendant did not need to be disqualified. Therefore, the judgment was affirmed.

The relevant facts considered by the court were that the plaintiff, Natural Therapy Acupuncture, P.C., was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co., and the defendant had denied the claims at issue on the ground that the plaintiff had failed to comply with a condition precedent to coverage, in that they had failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided by the court was whether the defendant's EUO requests were justified and whether the plaintiff had failed to comply with the requests. The holding of the case was that the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, as the defendant had established that the EUO scheduling letters and the denial of claim forms had been timely mailed and the plaintiff had failed to appear for the EUOs, and the plaintiff's objections regarding the EUO requests were not considered as they had not responded in any way. Therefore, discovery relevant to the reasonableness of the EUO requests was not necessary for the plaintiff to oppose the defendant's motion.

The relevant facts of the case were that an insurance company had timely mailed verification requests to a medical care provider, but had not received the requested verification. The main issue decided by the court was whether the insurance company had to prove that the copies of the verification letters had not been tampered with or altered. The court held that there was nothing in the record requiring the insurance company to prove that the copies had not been tampered with, and that as a result, the medical care provider's action was premature. Therefore, the court reversed the findings in favor of the medical care provider and granted the insurance company's cross motion for summary judgment dismissing the complaint.