No-Fault Case Law

The court considered a case that involved an action to recover damages for breach of contract and other causes of action. The plaintiff appealed a lower court order that granted multiple motions to dismiss the complaint. The court ultimately decided that the cause of action for fraud could not lie where based on the same allegations as a cause of action alleging breach of contract. They found that the fraud cause of action against the defendant State Farm Mutual Automobile Insurance Company was based on the same allegations as the breach of contract cause of action and properly granted the motion to dismiss. The court also found that the fraud cause of action against the remaining defendants should be dismissed, as the allegations were either bare and conclusory or did not rise to the level of fraud. However, the court erred in granting the motion to dismiss the first cause of action, which alleged breach of contract. The Supreme Court should have denied that branch of State Farm's motion. Additionally, the court properly granted the motion to dismiss the second cause of action, which sought consequential damages for breach of the no-fault insurance benefits policy.

The main issue in the case was whether an insurance company was justified in denying a healthcare provider's claim for first-party no-fault benefits on the grounds of insufficient verification being provided. The court had to consider whether the provider had failed to provide all the requested verification in a timely manner, and therefore whether the insurance company was within its rights to deny the claim. The court ultimately held that the insurance company was justified in denying the claim, as the provider had not demonstrated that they had provided all of the requested verification prior to the commencement of the action, and therefore the 30-day period within which the insurance company was required to pay or deny the claims had not begun to run. The court reversed the judgment, vacated the previous order, denied the provider's motion for summary judgment, and granted the insurance company's cross motion for summary judgment dismissing the complaint.

The relevant facts considered by the court in this case were that Eagle Surgical Supply, Inc. was seeking to recover first-party no-fault benefits as the assignee of a patient, Tristan Joris, and had brought a lawsuit against GEICO Insurance Co. The main issue decided was whether the supplies provided by Eagle Surgical Supply were medically necessary. The court found in favor of GEICO, stating that the supplies in question were not medically necessary, and dismissed the complaint. Eagle Surgical Supply appealed, arguing that the peer review report and underlying medical records should not have been admitted into evidence. The Appellate Term upheld the original judgment, stating that the lack of medical necessity had been properly established at trial through the testimony of GEICO's expert witness, and that Eagle Surgical Supply's objections lacked merit. Therefore, the judgment in favor of GEICO Insurance Co. was affirmed.

The court considered a case in which a provider sought to recover assigned first-party no-fault benefits from an insurance company. The insurance company denied the provider's claims, alleging that there was a "material misrepresentation" because the provider had billed for a heating pad that had not been provided to the assignor. The main issue decided was whether the provider was barred from receiving benefits not only for the heating pad but also for the remaining supplies for which they sought to recover. The holding of the court was that the insurance company failed to establish that the claim forms sought payment for medical supplies that were not actually provided, and that billing for a heating pad that was not delivered did not void the insurance policy. Therefore, the court affirmed the denial of the insurance company's motion to dismiss the claims for the remaining supplies.

The court considered the fact that after the plaintiff presented its case in a trial to recover first-party no-fault benefits, the defendant offered no defense but relied on the record. Despite the claim forms not containing language about an assignment of benefits, the defendant did not object to the completeness of the forms or seek verification of the existence of a valid assignment. The main issue decided was whether the plaintiff had established a prima facie case and whether the defendant waived any defense based on the absence of an assignment of benefits. The court held that the defendant waived any defense based on the absence of an assignment of benefits and that it was the defendant's burden to show a meritorious defense, therefore it reversed the previous judgment and remitted the matter to the Civil Court for the entry of a judgment in favor of the plaintiff in the principal sum of $2,063.10, plus statutory interest and attorney's fees.

The court considered the case of Radiology Today, P.C. as Assignee of BRIANT JOSEPH v. Travelers Insurance Company, where the plaintiff sought to recover first-party no-fault benefits. The main issue was whether the defendant had established a lack of medical necessity for the radiology services at issue. The court held that the defendant's expert witness testimony did not provide a factual basis or medical rationale for her opinion, therefore, it was insufficient to establish the lack of medical necessity for the services rendered. Additionally, the court ruled that a peer review report, unlike a witness, is not admissible to prove lack of medical necessity and is not subject to cross-examination. The Civil Court's determination that the defendant had not established that the services at issue were not medically necessary was upheld, and the judgment in favor of the plaintiff was affirmed.

The court considered the fact that the plaintiff, LK Health Products, Inc., objected to an Examination Under Oath (EUO) request made by defendant GEICO General Insurance Company, citing the New York No-Fault Regulations. The main issue decided was whether the defendant insurance company was required to respond to the plaintiff's objection to the EUO request as being unreasonable. The court held that the plaintiff timely objected to the EUO request, but the defendant provided evidence justifying the need for the EUO, based on an investigation into the plaintiff for improper billing practices. Therefore, the defendant was justified in requesting the EUO, and the plaintiff's failure to show up for the EUO constituted a violation of a condition precedent to coverage, voiding the contract ab initio. As a result, the defendant was not obligated to pay the claim, and the case was dismissed with prejudice.

The relevant facts that the court considered in this case were that Art of Healing Medicine, P.C. was seeking to recover first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint insofar as it sought to recover upon a claim in the amount of $2,619.20. The holding of the court was that defendant did not establish its entitlement to summary judgment with respect to the $2,619.20 claim, as it did not deny the claim on the ground that the plaintiff's assignor had failed to appear for scheduled independent medical examinations. Additionally, the court found that plaintiff failed to establish its prima facie case with respect to the $2,619.20 claim as it did not prove the fact and the amount of the loss sustained. Therefore, the court modified the order and held that plaintiff had not established its prima facie case with respect to the claim.

The court considered an action by a provider to recover assigned first-party no-fault benefits. Plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The main issue was whether the supply at issue was medically necessary. The court found that defendant had established a timely and proper denial of the claim at issue on the ground of lack of medical necessity and that the sole remaining issue for trial was medical necessity. The court held that defendant's cross motion for summary judgment dismissing the complaint was granted, as plaintiff did not challenge the Civil Court's finding that defendant was entitled to judgment.

The relevant facts in this case included a medical provider's attempt to recover no-fault benefits from an insurance company. The insurance company had denied the claim based on the medical provider's failure to appear for scheduled examinations under oath (EUOs). The main issue decided was whether the insurance company had proven that it had mailed the EUO scheduling letters and denial of claim forms on time, and whether the medical provider had failed to comply with the condition precedent to coverage. The holding of the case was that the insurance company had indeed timely mailed the EUO scheduling letters and denial of claim forms, and the medical provider's failure to respond to the EUO request meant that their objections regarding the request could not be heard. As a result, the order to grant the insurance company's motion for summary judgment dismissing the complaint was affirmed.