No-Fault Case Law

The court considered a provider's claim for first-party no-fault benefits, specifically the issue of severance of the first cause of action, seeking to recover for services rendered to Yolanda Deleon, from the remaining causes of action following five accidents and multiple defenses interposed in the answer. The main issue decided was whether to grant severance of the claims, an exercise of judicial discretion that should not be disturbed on appeal in the absence of a showing of prejudice to a substantial right. The court held that the denial of defendant's motion for severance was not an improvident exercise of discretion, as the resolution of the claim for services rendered to Yolanda Deleon will involve different questions of fact and law from the claims for services rendered to the other assignors. Therefore, the order denying defendant's motion for severance was affirmed.

Facts: New York Center for Specialty Surgery (Specialty Surgery) sought payment from State Farm Insurance Company for manipulation under anesthesia (MUA) procedures performed on Jennifer Barrera, which State Farm deemed medically unnecessary. A bench trial was held, and the parties stipulated to the timeliness of claims and denials, as well as the expertise of the chiropractor who performed the procedures. After reviewing the treatment records and bills, the court found justification for each MUA procedure based on the patient's medical and treatment history. Issues: The main issue in this case was whether the MUA procedures performed by Specialty Surgery on Jennifer Barrera were medically justified and exceeded the scope of chiropractic practice, and if State Farm was obligated to pay for the procedures. Decision: The court held that the MUA procedures were justified based on the patient's medical history and the National Academy of Manipulation Under Anesthesia Physicians (NAMUA) protocols, which recommend such procedures for patients experiencing intractable pain that interferes with their lifestyle. The court also found that the procedures did not exceed the scope of chiropractic practice, as the manipulation of the patient's spine was within the scope of chiropractic treatment. Therefore, the court directed the clerk to enter judgment in favor of Specialty Surgery in each of the three matters, ordering State Farm to pay for the MUA procedures.

The main issues in this case were whether the Civil Court had jurisdiction over a claim for reimbursement under a no-fault automobile insurance policy, and whether the Workers' Compensation Board had exclusive jurisdiction over the underlying accident. The relevant facts considered by the court were that the plaintiff, Happy Apple Medical Services, PC, was seeking to recover assigned first-party No-Fault benefits for medical treatment provided to the assignor, Mario Eustache. The defendant, Liberty Mutual Insurance Company, argued that the Court lacked subject matter jurisdiction over the underlying causes of action due to the accident being deemed work-related by the Workers' Compensation Board. The Court held that the Workers' Compensation Board has primary jurisdiction, but not necessarily exclusive jurisdiction, over issues concerning the compensability of an accident. However, the causes of action before the Civil Court were for monetary damages relating to unpaid invoices and attorneys' fees in accordance with a no-fault insurance policy, which fell within the Civil Court's jurisdiction. The Court determined that the matter before it was not a determination of a workers' compensation claim, but rather a claim for reimbursement under a no-fault automobile insurance policy. Therefore, the Court had jurisdiction to adjudicate the causes of action related to the reimbursement and defenses under the no-fault insurance policy. As a result, the Defendant's motion to dismiss was denied.

The civil court heard a case in which Sayyed DC, P.C., as assignee of Martinez, sued Ameriprise Insurance Company to recover $2,034.58 in unpaid first party No-Fault benefits for chiropractic services provided to Martinez throughout 2018, as well as attorneys' fees and statutory interest. The main issue was whether the insurance company failed to attend scheduled Examinations Under Oath (EUO) and failed to timely submit a claim to the insurer, and if the insurance company established a prima facie case. The court's holding was that the insurance company's motion for summary judgment was granted in part to dismiss some of the plaintiff's causes of action, but was otherwise denied. The plaintiff's cross-motion was granted in part, and one cause of action was allowed to proceed to trial. The court also decided that determination of attorneys' fees was premature and would be addressed during or upon the conclusion of the trial.

The relevant facts that the court considered in this case involve Barakat P.T., P.C., who filed a case against Progressive Insurance Company seeking to recover assigned first-party no-fault benefits in the amount of $141.62. The main issues were whether the fees charged exceeded the Workers' Compensation fee schedule and if a claim was subject to a $200 deductible. The court held that because the defendant denied the bill in its entirety based on the explanation of benefits and that the amount allowed was within a deductible, the defendant was entitled to summary judgment dismissing the complaint. The court ruled in favor of the defendant and dismissed the complaint.

The court considered an appeal from an order of the Civil Court denying the defendant's motion for summary judgment dismissing the complaint in a case involving a provider seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the out-of-state insurance company, defendant, was liable for the services under the insurance policy at issue. The defendant argued that, as an out-of-state company with no ties to New York, it was not liable for the services. However, the court held that the defendant had not demonstrated, as a matter of law, that its policies should not be deemed to satisfy New York's financial security requirements and provide for the payment of first-party benefits, as mandated by Insurance Law § 5107 and 11 NYCRR § 65-1.8. Therefore, the order denying the defendant's motion for summary judgment was affirmed.

In this case, Metropolitan Medical, P.C. sought to recover assigned first-party no-fault benefits from Allstate Insurance Co. A judgment was initially entered on August 10, 2007, awarding statutory no-fault interest. Plaintiff subsequently moved to have the interest recalculated at a compound rate, which was denied on the grounds that the court could not determine the relevant dates. Plaintiff then sought to renew its motion with new evidence, and the Civil Court granted the motion, ordering the interest to be calculated at a compound rate. The court also provided that postjudgment interest would accrue at 9% annually. Allstate Insurance Co. appealed the decision to calculate the interest at a compound rate, but the Appellate Term affirmed the order, stating that plaintiff established reasonable justification for its failure to submit the claim forms and that the motion to renew was properly granted. The cross-appeal by plaintiff was dismissed. Thus, the decision held that the interest should be calculated at a compound rate, and the order was affirmed.

The New York Supreme Court, New York County considered a no-fault insurance action wherein Liberty Mutual Insurance Company sued to determine no-coverage against Jason Carranza and various medical providers. Liberty Mutual sought a default judgment against Carranza and the medical-provider assignees. The court ruled against Liberty Mutual, denying the motion for a default judgment based on lack of proof of the facts necessary to constitute its claim and non-compliance with regulatory timeliness requirements. Additionally, the court granted a cross-motion from the defaulting medical-provider assignees to compel Liberty Mutual to accept their late answer, finding that they had provided an excuse for the delay and established a potentially meritorious defense. The court ordered Liberty Mutual to either bring a renewed default-judgment motion within 30 days or face the dismissal of the action as to the remaining defaulting defendants.

The Appellate Court considered the case of Active Care Medical Supply Corp. v. Global Liberty Insurance, in which the plaintiff was seeking to recover assigned first-party no-fault benefits. The issue before the court was whether the Worker's Compensation was primary in determining the liability for the benefits. After a nonjury trial, the court found in favor of the plaintiff, ruling that the defendant's certified transcript of an examination under oath of the plaintiff's assignor was not admissible based on law of the case. The defendant then moved to set aside the decision and for a new trial, pursuant to CPLR 4404, but this was denied by the Civil Court. The Appellate Court reversed the decision of the Civil Court, holding that it should have considered the certified EUO transcript to determine whether the defendant had proffered sufficient evidence to support its contention that there was an issue as to whether the plaintiff's assignor had been acting in the course of his employment at the time of the accident. Therefore, the defendant's motion for a new trial was granted.

The Court considered whether the failure of an eligible injured person (EIP) to attend an independent medical examination (IME) is a "policy issue" for the purpose of the no-fault insurance law denial of claim form and an award of hourly attorneys' fees under the New York Insurance Department Regulations. The main issue decided was that an EIP's failure to attend an IME is indeed a "policy issue" and plaintiff may be awarded attorneys' fees pursuant to the regulations. It was concluded that the insurer who denies a claim for first-party No-Fault benefits on the basis of the injured person's failure to attend an IME properly does so by checking the specific box on the denial of claim form, and so it is considered a "policy issue" for the purposes of awarding attorneys' fees under the regulations. The holding was that, while plaintiff may be awarded attorneys' fees in this case under the regulations, it is entirely unclear from the record whether the amount that was awarded was calculated correctly. Therefore, the matter was remanded for further proceedings and for an amended judgment.