No-Fault Case Law

The court considered an appeal from the denial of a motion for summary judgment in a case where a provider sought to recover assigned first-party no-fault benefits from an insurance company. The main issue was whether the insurance company had a duty to provide coverage for the accident at issue in the case, based on a declaratory judgment entered in the Supreme Court, New York County. The court held that, for the reasons stated in a similar case (St. Mark's Med. Health Care, PLLC as Assignee of Dejean, Ludmilla v 21st Century Ins. Co.), the insurance company's motion for summary judgment dismissing the complaint should have been granted. Therefore, the order denying the insurance company's motion for summary judgment was reversed, and the insurance company's motion was granted.

The court considered the appeal from an order of the Civil Court of the City of New York, Kings County, which denied the defendant's motion for summary judgment dismissing the complaint in a case regarding first-party no-fault benefits. The main issue decided was whether the defendant had a duty to provide coverage for the accident at issue, based on a declaratory judgment entered in the Supreme Court, New York County. The holding of the court was that, for the reasons stated in another case, the order denying the defendant's motion for summary judgment was reversed, and the defendant's motion for summary judgment dismissing the complaint was granted. Therefore, the defendant was found not to have a duty to provide coverage for the accident.

The relevant facts of this case involved St. Mark's Medical Health Care, PLLC commencing an action against 21st Century Insurance Company to recover assigned first-party no-fault benefits for services provided to its assignor, who had been injured in an accident. Prior to the commencement of the action, 21st Century Advantage Insurance Company and 21st Century Security Insurance Company had brought a declaratory judgment action against St. Mark's Medical Health Care's assignor pertaining to the accident. The Supreme Court granted a motion by 21st Century Advantage Insurance Company and 21st Century Security Insurance Company for a default judgment against the provider and assignor, ordering that they had "no duty to provide coverage" for the accident at issue. The main issue decided by the court was whether the Supreme Court's order and judgment had res judicata effect and thus precluded St. Mark's Medical Health Care from relitigating the same claims in the Civil Court. The court held that the default judgment from the Supreme Court had res judicata effect and granted 21st Century Insurance Company's motion for summary judgment dismissing the complaint. Therefore, the holding of the case was that the Civil Court should have granted the defendant's motion for summary judgment dismissing the complaint based on the res judicata effect of the Supreme Court's default judgment.

The case involved an appeal from an order of the Civil Court of the City of New York, Kings County, which granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment dismissing the complaint. The plaintiff, a provider seeking to recover assigned first-party no-fault benefits, had moved for summary judgment, while the defendant opposed the motion, arguing that the action was premature as the plaintiff had failed to respond to timely requests for additional verification. The court determined that the defendant's cross-motion was properly denied, as it had failed to establish that its requests for additional verification were proper or timely. However, the court also found that the plaintiff's motion for summary judgment should have been denied, as it had failed to establish that the claims at issue had not been timely denied or that the defendant had issued timely denial of claim forms that were conclusory, vague, or without merit as a matter of law. Therefore, the court modified the order to provide that the plaintiff's motion for summary judgment was denied.

The court considered the failure of the claimants to subscribe and return the transcripts of their examinations under oath (EUOs), which violated a condition precedent to coverage. Plaintiff's failure to present proof of proper delivery of the denials was also considered, along with defendants' failure to appear at two scheduled EUOs. The main issue decided was whether the claimants' failure to comply with the EUOs warranted denial of their claims and whether plaintiff was entitled to summary judgment. The court held that the claimants' failure to comply with the EUOs violated a condition precedent to coverage, and plaintiff was entitled to summary judgment, declaring that defendants have no right to collect said no-fault benefits. The court reversed the order and declared that defendants have no right to collect no-fault benefits.

The relevant facts that were considered in this case were that the plaintiff, a New Jersey medical provider, sought to recover first-party no-fault benefits against the defendant, an insurance company, for medical services provided to an individual injured in a motor vehicle accident. The plaintiff alleged that the insured assigned first-party no-fault benefits to it but the defendant had failed to pay for the medical services. The main issue decided in this case was whether the defendant was entitled to summary judgment dismissing the complaint on the grounds that the claimed expenses were not medically necessary and that one particular expense was not reimbursable under the applicable New Jersey medical fee schedule for Automobile Insurance Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage. The holding of the court was that the defendant failed to make a prima facie showing that the services provided were not medically necessary and that the disputed surgical device was not reimbursable, thus raising a triable issue of fact as to medical necessity and the eligibility of the disputed device for reimbursement. Therefore, the Supreme Court's determination denying the defendant's motion for summary judgment dismissing the complaint was affirmed.

The court considered the case of Madison Products of USA, Inc. as assignee of Pierre, Luxio against American Transit Ins. Co. The main issue decided was whether workers' compensation benefits might be available to the plaintiff's assignor, who had been injured during the course of his employment at the time of the accident. The court held 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, and that the determination of the applicability of the Workers' Compensation Law was vested in the Workers' Compensation Board. As a result, the court modified the order to hold the plaintiff's motion in abeyance until it is ripe for determination, and remitted the matter to the Civil Court for a new determination, following a framed issue hearing, of the branch of defendant's cross motion seeking to hold the fifth cause of action in abeyance pending a determination by the Workers' Compensation Board of the parties' rights under the Workers' Compensation Law.

The court considered the facts that the insurance company timely denied the claims due to the plaintiff's failure to appear for scheduled examinations under oath (EUOs) and that the initial EUO scheduling letter identified the assignor, the accident date, and the defendant's file number. The main issue decided was whether the EUO scheduling letters were defective, and if the plaintiff had failed to appear for the scheduled EUOs. The holding of the case was that the judgment was reversed, the order denying defendant's motion for summary judgment was vacated, the defendant's motion for summary judgment dismissing the complaint was granted, and plaintiff's cross motion for summary judgment was denied. The insurance company had timely denied the claims due to the plaintiff's failure to appear for the EUOs, and the plaintiff failed to raise a triable issue of fact in opposition.

In the case Longevity Med. Supply, Inc. v Progressive Ins. Co., the court considered the fact whether Progressive Insurance Company was liable to pay no-fault benefits to Longevity Medical Supply, Inc. which was the assignee of Saddiq Waiters, who was involved in a motor vehicle accident. The main issue in the case was the failure of Saddiq Waiters to appear for an independent medical examination (IME) scheduled on two occasions as required by Progressive Insurance Company to process the claim. The court held that Progressive Insurance Company met its prima facie burden to establish that it properly mailed scheduling letters for IMEs, but failed to establish that the claimant failed to appear for the IMEs. Therefore, the court denied the defendant's motion for summary judgment. The court found that both affidavits submitted by the defendant were insufficient and the defendant had not met its burden to establish that the claimant failed to appear for the IME.

The court considered the fact that the plaintiff filed an action against the defendant seeking to recover $5,503.90 in assigned no-fault insurance benefits. The main issues decided were whether the plaintiff had standing to receive the reimbursement, the medical necessity of the treatment, and the proper payment under the fee schedule. The court held that the plaintiff did have standing to receive reimbursement, denied the defendant's motion on the Mallela defense, found a material issue of fact exists as to the medical necessity of the treatment, and denied the defendant's motion for summary judgment as to the proper payment under the fee schedule. The plaintiff's cross motion for summary judgment was also denied in its entirety.