No-Fault Case Law
Delta Diagnostic Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51953(U))
October 16, 2012
The court considered the fact that the defendant, a medical services provider, was seeking to recover first-party no-fault benefits from the insurance company. The defendant had moved for summary judgment to dismiss the complaint, with the central issue being whether the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs), which was a condition precedent to the insurer's liability on the policy. The insurance company submitted evidence, including an affidavit of an employee of the entity that scheduled the IMEs and affirmations of its doctors, establishing that the plaintiff's assignor had indeed failed to appear for the scheduled IMEs. The court held that since the plaintiff had only submitted an affirmation from its counsel, it had failed to raise a triable issue of fact. Therefore, the court ruled in favor of the insurance company, granting its motion for summary judgment and dismissing the complaint.
Smooth Dental, P.L.L.C. v Preferred Mut. Ins. Co. (2012 NY Slip Op 22301)
October 16, 2012
The case involved an action to recover assigned first-party no-fault benefits for dental services provided to plaintiff's assignor as a result of injuries sustained in an automobile accident. Defendant Preferred Mutual Insurance Company had previously commenced a declaratory judgment action against plaintiff's assignor, in which it was declared not obligated to provide no-fault benefits or defend any claims for bodily injury or property damage on its policy issued to the assignor. The main issue in this case was whether the instant action was barred by virtue of the order in the declaratory judgment action. The court held that plaintiff was not subject to dismissal by virtue of the order in the declaratory judgment action, as it was neither named nor served in that action and had no full and fair opportunity to appear and defend its interests in that proceeding. As a result, the defendant's motion for summary judgment was properly denied, and the order of the Civil Court was affirmed.
EBM Med. Health Care, P.C. v Republic W. Ins. (2012 NY Slip Op 22300)
October 16, 2012
The court considered the fact that EBM Medical Health Care, P.C. had commenced an action to recover first-party no-fault benefits for medical services provided to its assignor as a result of injuries sustained in an automobile accident. The insurance company Republic Western Insurance initiated a declaratory judgment action alleging that EBM was not properly licensed to recover no-fault benefits. A judgment was entered, on default, in the declaratory judgment action where Republic had no duty to pay no-fault benefits to EBM. After the judgment in the declaratory judgment action, Republic moved in this no-fault action for summary judgment dismissing EBM's complaint. The main issue decided was whether the no-fault action was barred by virtue of the declaratory judgment. The holding of the court was that the instant action was barred under the doctrine of res judicata and that the no-fault action falls within the ambit of the declaratory judgment as a "current" proceeding. Therefore, the order of the Civil Court was reversed and Republic's motion for summary judgment dismissing the complaint was granted.
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.