No-Fault Case Law
Ayoob Khodadadi, M.D.,MRI, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51968(U))
October 11, 2012
The relevant facts the court considered in this case were that the defendant had timely mailed denial of claim forms, denying the claims on the ground of lack of medical necessity. The defendant also submitted the affirmed reports of its peer reviewer, which set forth a factual basis and medical rationale for the doctor's opinion that there was a lack of medical necessity for the services provided to the plaintiff's assignor. In response, the plaintiff failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity. The main issue decided by the court was whether the defendant established its prima facie entitlement to summary judgment, and whether the plaintiff submitted sufficient evidence to raise a triable issue of fact as to medical necessity. The holding of the court was that the order granting the plaintiff's motion for summary judgment was reversed, and the defendant's cross motion for summary judgment dismissing the complaint was granted.
Rainbow Med. Care, P.C. v Kemper Ins. Co. (2012 NY Slip Op 51923(U))
October 5, 2012
The relevant facts considered by the court in Rainbow Med. Care, P.C. v Kemper Ins. Co. included the timely scheduling of independent medical examinations (IMEs) and the assignor's failure to appear for the IMEs. The main issue decided by the court was whether the defendant had established that the IME scheduling letters had been timely mailed, and whether the assignor's failure to appear for the IMEs had been sufficiently established. The holding of the court was that the defendant had sufficiently established the timely mailing of the IME scheduling letters, as well as the assignor's failure to appear for the IMEs. Therefore, the court granted the defendant's motion for summary judgment dismissing the complaint.
Okslen Acupuncture, P.C. v N.Y. Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51887(U))
October 3, 2012
The relevant facts of the case were that Okslen Acupuncture, P.C. brought a lawsuit against NY Central Mutual Fire Ins. Co. for failing to timely deny the claim for first-party no-fault benefits within the prescribed 30-day period. The main issue decided was whether the defendant insurer was precluded from asserting the defense that the fees charged were excessive due to not timely denying the claim. The holding of the case was that the defendant insurer was indeed precluded from asserting the defense, and the court granted plaintiff summary judgment in the principal amount demanded in the first cause of action. The court also did not pass upon plaintiff's request for statutory interest and attorneys' fees.
Alfa Med. Supplies v Utica Mut. Ins. Co. (2012 NY Slip Op 51890(U))
September 28, 2012
The relevant facts the court considered were that Alfa Medical Supplies appealed a judgment entered on a motion for summary judgment in their favor against Utica Mutual Insurance Company in a case to recover assigned first-party no-fault benefits. The main issue decided was whether defendant's denial of the $2,199 claim for supplies provided to Jose Cayetano was timely and justified and if the denial of the $1,750 claim for supplies provided to Argenis Plata-Gil was valid. The holding of the court was that the denial of the claim for supplies provided to Jose Cayetano was timely and justified, and the denial of the claim for supplies provided to Argenis Plata-Gil was not timely and therefore invalid, so the judgment was reversed and the claim for $2,199 for supplies provided to Jose Cayetano was denied.
Weiss v Tri-State Consumer Ins. Co. (2012 NY Slip Op 06294)
September 26, 2012
The court considered an action to recover damages pursuant to a supplementary uninsured/underinsured motorist endorsement of an insurance policy. The insurance policy, issued by Tri-State Consumer Insurance Company, contained a SUM endorsement with a coverage limit of $250,000 per person and $500,000 per accident. The insured's parents were killed in a car accident by a drunk driver who carried insurance with coverage limits of $50,000 per person and $100,000 per accident. The insured submitted a claim to the insurer under the SUM endorsement and an dispute arose over the amount of coverage available. The main issue decided was whether the amount of SUM coverage was reduced by the amount received from the Dram Shop defendants in a settlement agreement unrelated to the drunk driver's insurance. The court held that the amount received from the Dram Shop defendants did reduce the amount payable under the SUM endorsement, and that the claimant was not entitled to the full coverage amount under the SUM endorsement as claimed.
NYU-Hospital for Joint Diseases v Praetorian Ins. Co. (2012 NY Slip Op 06288)
September 26, 2012
The case involves an action to recover no-fault benefits under a policy of automobile insurance. NYU-Hospital for Joint Diseases, as the assignee of Gladys Feliz, appealed from an order granting the defendant's motion to vacate a default judgment and to compel the plaintiff to accept the defendant's answer. The Supreme Court granted the defendant's motion based on the lack of prejudice to the plaintiff from the delay, the lack of willfulness on the part of the defendant, the existence of a potentially meritorious defense, and the public policy favoring the resolution of cases on the merits. Due to these factors, the defendant's default in appearing or answering the complaint was properly excused according to the court.
Overall, the court considered the lack of prejudice to the plaintiff, the lack of willfulness on the part of the defendant, the potentially meritorious defense, and the public policy favoring the resolution of cases on the merits in deciding to affirm the order granting the defendant's motion to vacate the default judgment and to compel the plaintiff to accept the defendant's answer.
All Boro Psychological Servs., P.C. v Hartford Ins. Co. (2012 NY Slip Op 51849(U))
September 19, 2012
The relevant facts considered by the court were that the plaintiff, a provider seeking first-party no-fault benefits, had failed to appear at the scheduled examinations under oath (EUOs) as required by the insurance company. The main issue decided was whether the insurance company had met the conditions for liability on the policy by timely mailing the EUO scheduling letters and the denial of claim form, and whether the plaintiff's failure to appear at the EUOs was a valid defense for the insurance company. The holding of the court was that the insurance company had met the conditions for liability on the policy, and the plaintiff's failure to appear at the EUOs was a valid defense for the insurance company. Therefore, the court affirmed the judgment in favor of the insurance company.
Muhammad Tahir, M.D., P.C. v Travelers Prop. Cas. Ins. Co. (2012 NY Slip Op 51802(U))
September 19, 2012
The court considered the case of Muhammad Tahir, M.D., P.C. against Travelers Property Casualty Ins. Co., in which the defendant appealed a judgment in favor of the plaintiff awarding damages in the amount of $1,277.64. The main issue decided was whether the 30-day period within which an insurer must pay or deny a claim for first-party no-fault benefits is tolled until it receives a response to properly issued verification requests. The holding of the court was that the judgment in favor of the plaintiff was reversed and a judgment was awarded in favor of the defendant dismissing the complaint. This decision was based on evidence presented by the defendant that they had timely and properly mailed initial and follow-up verification requests to the plaintiff medical provider's attorney, as authorized by plaintiff's counsel's prior correspondence to the defendant, and that the plaintiff had failed to respond.
Arco Med. N.Y., P.C. v Lancer Ins. Co. (2012 NY Slip Op 22278)
September 19, 2012
The main issues in this case involved a provider seeking first-party no-fault benefits from an insurance company. The provider filed a motion for summary judgment, while the insurance company cross-moved to compel the provider to produce witnesses for depositions. The insurance company had failed to raise a triable issue of fact in opposition to the provider's motion for summary judgment in the lower court, but raised a triable issue with respect to some of the causes of action upon appeal. The main holding of the case was that the provider was entitled to summary judgment on the first two causes of action, but not on the third through ninth causes of action. The decision was modified to reflect the above.
RAZ Acupuncture, P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51826(U))
September 13, 2012
The court considered a dispute regarding unpaid medical bills for acupuncture services provided to a patient under a no-fault insurance claim. The main issue decided was whether the insurance company had fully paid the plaintiff for the acupuncture services rendered in accordance with the workers' compensation fee schedule. The court held that the insurance company had demonstrated that it had fully paid the plaintiff for the acupuncture services at issue in accordance with the workers' compensation fee schedule. Therefore, the judgment of the lower court, which dismissed the complaint insofar as it sought to recover for those claims, was affirmed.