No-Fault Case Law

The court considered the affidavits and evidence submitted by both the plaintiff and the defendant, in relation to a motion for summary judgment. The main issue decided was whether the defendant timely denied the plaintiff's claims for first-party no-fault benefits, and whether the fees charged by the plaintiff for acupuncture services exceeded the amount permitted by the applicable worker's compensation fee schedule. The court held that the defendant's motion for summary judgment dismissing the complaint was granted in its entirety, as the defendant established prima facie that it timely denied the claims and that the fees charged exceeded the permitted amount. The court found that the plaintiff failed to raise a triable issue regarding the efficacy of the denial or the calculation of the fee, and therefore the motion for summary judgment should have been granted in favor of the defendant.

The relevant facts presented to the court were that an automobile accident occurred in April 2011 and the owner and driver of the vehicle, Gregory Huff, assigned his no-fault insurance benefits to medical providers. The insurance company, American States Insurance Company, brought the action to argue that it was not obligated to pay the no-fault benefits to the medical providers due to Huff's failure to complete an Examination Under Oath (EUO) as required by the insurance policy. The company argued that this failure breached a condition precedent to coverage under the policy and therefore the medical providers were not entitled to recover Huff's no-fault benefits. The main issue decided by the court was whether the insurance company was justified in disclaiming coverage based on the insured’s failure to complete an EUO. The court held that the Supreme Court properly granted summary judgment in favor of the insurance company, declaring that the disclaimer of coverage was proper. The court affirmed the decision, finding that the EUO transcript was admissible evidence and that the defense of the breach of a condition precedent to coverage under the policy was valid against the medical providers who accepted assignments of no-fault benefits.

The court considered the defendant-insurer's argument that it was entitled to summary judgment dismissing the action for first-party no-fault benefits because it had properly and timely mailed notices for independent medical examinations (IMEs) to the plaintiff's assignor and his counsel, and the assignor failed to appear. The insurer presented affidavits from the scheduled examining physician and an employee of the insurer's third-party biller attesting to the assignor's nonappearance. The plaintiff did not specifically deny the assignor's nonappearance or raise a triable issue with respect to the mailing or reasonableness of the notices. The main issue decided was whether the insurer was entitled to summary judgment dismissing the complaint. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted in its entirety because the insurer made a prima facie showing of entitlement to summary judgment.

The relevant facts of Westchester Medical Center v Mapfre Insurance Company of New York involved an action to recover no-fault medical payments under an insurance contract. The plaintiff, Westchester Medical Center, sought to recover these payments from the defendant, Mapfre Insurance Company of New York, after they were not paid within 30 days of the defendant's receipt of the prescribed claim forms. The plaintiff moved for summary judgment on the complaint, but the defendant raised a triable issue of fact as to whether it timely and properly denied the claim based on the alleged intoxication of the plaintiff's assignor at the time of the accident by issuing a denial within 30 days of the receipt of additional verification it requested concerning the claim. Ultimately, the Supreme Court denied the plaintiff's motion for summary judgment on the complaint, and the order was affirmed by the Appellate Division. The main issue decided was whether the defendant sufficiently raised a triable issue of fact as to the timely and proper denial of the claim, and the holding was that they did, leading to the denial of the plaintiff's motion for summary judgment.

The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits, and the defendant moved for summary judgment dismissing the complaint based on the failure of the plaintiff's assignor to appear for scheduled examinations under oath (EUOs). The District Court denied the defendant's motion, and the defendant appealed. The main issues that were decided included whether the insurer's notice of scheduling an EUO needed to specify the reason(s) why the EUOs were being required, and whether the time to pay or deny a claim had been tolled by the timely issuance of EUO scheduling letters. The holding of the case was that the branches of the defendant's motion seeking summary judgment dismissing the first, fourth, and fifth causes of action of the complaint were granted in part and denied in part, and the order was modified accordingly.

The main issue in this case was whether the insurance company was justified in denying the plaintiff's claims for first-party no-fault benefits based on the plaintiff's failure to comply with a condition precedent to coverage, which was to appear for duly scheduled examinations under oath (EUOs). The court held that an appearance at an EUO is a condition precedent to the insurer's liability on the policy, and the insurance company was entitled to request the EUOs without specifying the reason for the request. The court also found that the opposing affirmation submitted by plaintiff's counsel was insufficient to raise a triable issue of fact in opposition to defendant's motion for summary judgment. Therefore, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The court considered a case where Meridian Psychological Services, PC provided psychological services to Kenroy Palmer after a motor vehicle accident. Meridian submitted the claim to Government Employees Insurance Co. (Geico) for payment, and Geico did not respond to the claim or pay or deny it. The main issue decided in the case was whether Geico was required to pay or deny the claim within 30 days of receipt, and whether Geico had properly followed up on the request for additional verification. The holding of the court was that Geico did not have a defense to the action brought by Meridian, as the claim had been timely submitted and Geico did not properly or timely follow up on its request for additional verification. Therefore, the court found in favor of the plaintiff, Meridian.

The court considered the provider's failure to comply with discovery requests, including the refusal to adequately comply with requests even after being directed to do so by court order. The main issue decided was whether the court should dismiss the complaint pursuant to CPLR 3126 due to plaintiff's willful and contumacious conduct in failing to comply with discovery requests and the absence of a reasonable excuse for its failure to comply. The holding of the court was that the order granting defendant's motion to dismiss the complaint with prejudice was affirmed, as the plaintiff's conduct was willful and in bad faith, warranting the drastic remedy of dismissal. The court also held that the remaining contention raised by the plaintiff for the first time on appeal was not properly before the court and therefore not considered.

In this case, the plaintiff sought to recover assigned first-party no-fault benefits for medical services provided to an assignor from October 19, 2000 through April 10, 2001. The defendant moved for summary judgment, claiming that the six-year statute of limitations had expired prior to the commencement of the action. The defendant's motion was denied, as the plaintiff provided evidence that the summons and complaint had been properly served on the defendant on March 25, 2003, within the statute of limitations period. The court found that the defendant's claim that the action had been previously dismissed was not substantiated by the record. Additionally, the defendant's submission of an answer in 2008 and service of discovery demands acted as a waiver of any right to dismiss the 2003 complaint. Therefore, the court affirmed the denial of the defendant's motion for summary judgment.

The relevant facts considered by the court in Forest Rehabilitation Medicine PC v Allstate Ins. Co. were that the plaintiff sought reimbursement for a relatively new and controversial form of pain management known as Calmare pain therapy, which had been administered to their assignor, Tracy Fertitta, after a motor vehicle accident. The court heard expert testimony from both the plaintiff and defendant, with the plaintiff's expert asserting that the therapy was reliable, had gained wide acceptance in the medical community, and had received FDA approval. The defendant's expert, however, argued that the treatment was not medically necessary and was not cost-effective. The main issue decided by the court was whether Calmare pain therapy was medically necessary and generally accepted as reliable science. The court ultimately held in favor of the plaintiff, finding that there was insufficient evidence to establish a lack of medical necessity for the Calmare pain therapy. The court concluded that, based on expert testimony and independent testing, the treatment was a medical necessity for the management of the patient's pain. Therefore, the court awarded judgment in favor of the plaintiff in the amount of $3,490, in addition to attorney's fees and statutory interest.