No-Fault Case Law

The relevant facts in this case include an action by a provider to recover assigned first-party no-fault benefits. The defendant alleged that the amount of available coverage had been exhausted after partially denying the claims that are the subject of the action and making subsequent payments. However, the court found that this allegation did not warrant summary judgment dismissing the complaint on the basis of an exhaustion of available coverage defense. The defendant also argued that it had fully paid the claims in accordance with the workers' compensation fee schedule, but failed to demonstrate, as a matter of law, that the fees charged exceeded the amount set forth in the workers' compensation fee schedule. Therefore, the court reversed the order and denied defendant's motion for summary judgment dismissing the complaint. The main issue decided in this case was whether the defendant's allegations of exhausting the available coverage and fully paying the claims in accordance with the workers' compensation fee schedule warranted summary judgment dismissing the complaint. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was denied because the allegations did not warrant such a dismissal.

The court considered the fact that the plaintiff, a provider, failed to appear for duly scheduled examinations under oath (EUOs) and the insurer issued a timely denial of the claims. The main issue decided was whether the defendant insurer was entitled to summary judgment dismissing the complaint based on the plaintiff's failure to appear for the EUOs. The court held that the insurer must demonstrate, as a matter of law, that it twice duly demanded an EUO from the provider, that the provider twice failed to appear, and that the insurer issued a timely denial of the claims, which the insurer had established. The court also held that the plaintiff failed to raise a triable issue of fact, and therefore the defendant was entitled to summary judgment dismissing the complaint.

The court considered the facts of the case, where an insurance company sought to dismiss a complaint by a medical supply company for failure to provide discovery. The medical supply company had entered into a stipulation agreeing to provide responses to the insurance company's demands for discovery within 60 days, but failed to do so. The main issue decided was whether the lower court was correct in granting the insurance company's motion to dismiss the complaint. The holding of the case was that the lower court had erred in granting the motion to dismiss, as the medical supply company's failure to comply with discovery demands was not willful, contumacious, or in bad faith. As a result, the judgment was reversed and the case was remanded for the medical supply company to provide the requested discovery within 60 days.

The relevant facts the court considered in Total Chiropractic, P.C. v Hereford Ins. Co. include an action by a provider to recover assigned first-party no-fault benefits. The appellant, Hereford Insurance Co., appealed from an order of the Civil Court which granted the plaintiff's motion for summary judgment and denied the appellant's cross motion. The appellant argued that the plaintiff failed to make a prima facie showing of its entitlement to summary judgment and that it is entitled to summary judgment dismissing the complaint based on the plaintiff's assignor's failure to appear for independent medical examinations (IMEs). The main issue that was decided is whether the plaintiff made a prima facie showing of its entitlement to summary judgment and whether the appellant is entitled to summary judgment dismissing the complaint based on the plaintiff's assignor's failure to appear for IMEs. The holding of the case was that the judgment is reversed, so much of the order entered September 12, 2018 as granted plaintiff's motion for summary judgment is vacated, and plaintiff's motion is denied. Therefore, the appellant was not entitled to summary judgment dismissing the complaint based on the plaintiff's assignor's failure to appear for IMEs.

The relevant facts were that Live In Grace Acupuncture, P.C. sued GEICO General Ins. Co. to recover first-party no-fault benefits, and GEICO cross-moved for summary judgment to dismiss the complaint, claiming it had fully paid the plaintiff in accordance with the workers' compensation fee schedule for services billed under CPT codes 97813 and 97814 for acupuncture services. The main issue decided was whether GEICO had fully paid Live In Grace Acupuncture, P.C. in accordance with the workers' compensation fee schedule for the services at issue. The court held that defendant demonstrated that it had fully paid plaintiff in accordance with the workers' compensation fee schedule for the services billed under CPT codes 97813 and 97814 for acupuncture services that plaintiff had rendered after April 1, 2013. As a result, the branch of defendant's cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims using CPT codes 97813 and 97814 was granted and plaintiff's motion for summary judgment upon those claims was denied.

The Court considered an appeal from an order of the Civil Court of the City of New York, which granted the defendant's motion for summary judgment dismissing the complaint and denied the plaintiff's cross motion for summary judgment. The main issue decided was whether the defendant's motion for summary judgment should have been denied, and if the plaintiff's arguments against it were properly before the court. The holding was that all of the plaintiff's arguments as to why the defendant's motion for summary judgment should have been denied were not properly before the court, as they were being raised for the first time on appeal, and were therefore declined to be considered. As a result, the Court affirmed the order.

The main issues decided in this case involved a dispute over whether an insurance company had a duty to pay no-fault benefits to a medical provider. The court found that the insurer's evidence, including affidavits attesting to regular business procedures and practices, provided sufficient proof of proper mailing of notices of scheduled IME exams to the claimant. Although the notices incorrectly added a "1st Floor" designation to the address, there was no dispute that the address was otherwise correct and that the claimant resided at that building. The burden then shifted to the defendant, who failed to offer any evidence in opposition, such as an affidavit from the claimant disavowing receipt of the IME notices, or even describing the building in a way that would support an inference that the inclusion of a floor in the address would result in nonreceipt. Therefore, the court held that the defendant's claims to no-fault benefits for its medical services rendered to the claimant were denied.

The relevant facts considered by the court were that LVOV Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits from Nationwide Ins. Co. The court granted the defendant's motion for summary judgment, dismissing the complaint on the grounds that the defendant had already fully paid the plaintiff for the services in question. The main issue decided in this case was whether the defendant had fulfilled its obligation to pay the plaintiff for the services at issue. The holding of the court was that the order granting the defendant's motion for summary judgment was affirmed, with $25 costs. This decision was in line with the court's reasoning in a related case, and was made by Justices Aliotta, Elliot, and Siegal.

The court considered the case of NL Quality Medical, P.C., who appealed an order of the Civil Court that granted GEICO Ins. Co.'s motion for summary judgment dismissing the complaint and denied the plaintiff's cross motion for summary judgment. The main issue was whether the proof submitted by the defendant was sufficient to give rise to a presumption that certain documents had been timely mailed and to demonstrate that the plaintiff had failed to comply with a condition precedent to coverage. The holding of the case was that the court modified the order by denying the branch of defendant's motion seeking summary judgment dismissing the second cause of action, as they found that an issue of fact exists as to whether the plaintiff is entitled to recover any additional reimbursement with respect to the services. Therefore, the branch of plaintiff's cross motion seeking summary judgment upon the second cause of action was properly denied.

The court considered the motion for summary judgment filed by the defendant, Nationwide Ins. Co., in a case brought by LVOV Acupuncture, P.C., as the assignee of Ozhan Tastaban, to recover first-party no-fault benefits. The main issue decided was whether the defendant had properly used the workers' compensation fee schedule to determine the amount owed to the plaintiff for the services in question. The court held that the defendant had fully paid the plaintiff for the services at issue, and that the affidavit executed by the defendant's certified medical coder established that the defendant had properly used the workers' compensation fee schedule. The court found that the plaintiff failed to rebut the defendant's showing, and affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.