No-Fault Case Law

The court considered the facts that an insurance company had denied a chiropractic clinic's claim for first-party no-fault benefits on the grounds that the clinic's assignor had failed to appear for scheduled independent medical examinations (IMEs). The main issue decided was whether the insurance company was entitled to partial summary judgment dismissing the second and third causes of action based on the assignor's failure to attend the IMEs. The holding of the case was that the insurance company was entitled to partial summary judgment dismissing the second and third causes of action, as the assignor had failed to comply with a condition precedent to coverage and the insurance company had timely denied the claims on that ground. The court also held that the assignor's denial of receipt of the IME scheduling letters was insufficient to rebut the presumption that the letters were received. Therefore, the insurance company's motion was granted and the order was reversed.

The relevant facts of the case revolve around a motor vehicle accident in 2008, where the plaintiff's car was struck from behind by a sanitation truck. As a result, the plaintiff underwent surgery to remove his L5-S1 disc and replace it with an artificial lumbar disc. The defendant, the plaintiff's insurance company, denied the claim for first-party no-fault benefits on the grounds that the surgery was not medically necessary. The main issue before the court was whether the plaintiff was entitled to recover the first-party no-fault benefits under his insurance policy to cover the cost of his surgery. The court held that the plaintiff made a prima facie showing of entitlement to judgment as a matter of law by submitting evidence that the statutory billing forms were mailed and received, and that the payment of no-fault benefits was overdue. The court also found that the plaintiff had standing to pursue his claims for no-fault benefits and affirmed the judgment in favor of the plaintiff in the principal sum of $44,573.86.

The court considered a case concerning no-fault insurance benefits following a car crash, including the failure of individual claimants to appear for properly-noticed examinations under oath, an allegation that the crash was intentional or staged, and a claim of non-coverage based on the named insured's failure to cooperate with the investigation of the claim. The main issue decided was whether the defaulting defendants' failures constituted a breach of a condition precedent to coverage and whether there was sufficient evidence for entry of a default judgment. The holding of the case was that the plaintiff had established that the failure of the individual claimants to appear for examinations under oath and the intentional/staged nature of the crash warranted a default judgment in favor of the plaintiff, and that the plaintiff had also submitted sufficient evidence warranting a default judgment for the named insured's failure to cooperate with the investigation of the claim.

The court considered the application for default judgment by Unitrin Safeguard Insurance Company against multiple defendants in a no-fault insurance coverage action. The defendants failed to answer or otherwise appear in the case, leading to default judgment being sought. Quality Ortho Complete Joint Care, P.C. filed a cross-motion to dismiss Unitrin's claims against it under CPLR 3215 (c) and CPLR 3211 (a) (4). The main issues before the court were whether Unitrin was entitled to default judgment against the defendants, and whether Quality Ortho's cross-motion to dismiss Unitrin's claims could be granted. The court granted Unitrin's motion for default judgment against the defendants who failed to appear, as there was sufficient evidence of service and founded belief that the claimants' injuries did not arise from a covered collision. The court also granted Quality Ortho's cross-motion to dismiss only to the extent of directing consolidation of this action with a parallel action brought by Unitrin against Quality Ortho, as the first-in-time rule generally governs motions to dismiss under CPLR 3211 (a) (4).

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits, but the defendant argued that the plaintiff's assignor failed to appear for scheduled examinations under oath (EUOs). The main issue decided was whether the defendant had established, prima facie, that the EUO letters were timely and properly mailed, and whether the plaintiff's assignor failed to appear for the scheduled dates. The holding of the court was that the defendant did establish, prima facie, that the EUO letters were timely and properly mailed, and that the plaintiff's assignor did fail to appear on the scheduled dates, thus affirming the order granting the defendant's motion for summary judgment dismissing the complaint.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits. The provider appealed from an order of the Civil Court that granted the defendant's motion seeking summary judgment dismissing part of the complaint related to claims for services billed using specific CPT codes. The defendant had paid the claims in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The court affirmed the order, ruling in favor of the defendant. The court held that the claims were properly paid under the workers' compensation fee schedule, and therefore, the provider was not entitled to recover on those claims.

The relevant facts considered by the court in this case were that the plaintiff, John A. Nasrinpay, was seeking to recover assigned first-party no-fault benefits from the defendant, Travelers Insurance Company. The defendant had filed a motion for summary judgment dismissing the complaint, which was granted by the Civil Court, and the plaintiff's cross motion for summary judgment was denied. The main issue decided was whether the defendant's lack of coverage defense was established, prima facie, and whether the plaintiff had demonstrated the existence of a triable issue of fact. The holding of the court was that as the defendant had submitted an affidavit and documentary evidence establishing its lack of coverage defense, and the plaintiff had failed to demonstrate the existence of a triable issue of fact, the Civil Court properly granted the defendant's motion for summary judgment and denied the plaintiff's cross motion for summary judgment. Therefore, the order was affirmed.

The court considered the provider's appeal to recover assigned first-party no-fault benefits, which included claims for services billed using specific CPT codes and services performed on or after August 10, 2016. The main issue decided was whether the defendant's motion for summary judgment to dismiss the claims was valid, as well as the plaintiff's cross motion for summary judgment. The court held that the affidavit submitted by the plaintiff failed to raise a triable issue of fact regarding the lack of medical necessity for the services performed after August 10, 2016. Additionally, the court affirmed the dismissal of the claims for acupuncture services billed using CPT codes 97810 and 97811, based on a previous case with similar circumstances.

The court considered a case where UGP Acupuncture, P.C. sought to recover first-party no-fault benefits from GEICO Ins. Co. The main issue decided was whether GEICO Ins. Co. had properly paid claims using specific CPT codes in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The court ultimately held that the order from the Civil Court, which denied UGP Acupuncture, P.C.'s motion for summary judgment and granted GEICO Ins. Co.'s cross motion seeking summary judgment dismissing the claims billed using those specific CPT codes, was affirmed. The decision was based on the reasoning and decision in a similar case, Mind & Body Acupuncture, P.C., as Assignee of Wilson, Bernadette v State Farm Mut. Auto. Ins. Co. The holding of the case was ultimately in favor of GEICO Ins. Co.'s decision to dismiss the claims billed using the specific CPT codes.

The court considered whether the plaintiff, New York Wellness PT, P.C., as assignee of Sang, Kashana, was entitled to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co. The main issue was whether defendant's motion for summary judgment dismissing the complaint should be granted on the ground that plaintiff's assignor failed to appear for duly scheduled examinations under oath (EUOs) and whether plaintiff's cross motion for summary judgment should be denied. The holding was that defendant's motion for summary judgment was denied, as the court found that defendant failed to establish its entitlement to summary judgment dismissing the complaint on the ground that plaintiff's assignor had failed to appear for EUOs. Additionally, plaintiff failed to demonstrate prima facie entitlement to judgment as a matter of law, so defendant's motion for summary judgment was denied.