Did the insurer prove the policy’s no-fault limits were properly exhausted before it became obligated to pay the claim?

Short answer: The departments are split. The core rule is settled in both departments that have decided it: once the insurer has paid the full no-fault limit its duties cease and it need not pay further claims (Presbyterian Hosp. v Liberty Mut., 2d Dept 1995; Countrywide v Sawh, 1st Dept 2000; NY & Presbyt. v Progressive and HJD v State Farm, 2d Dept 2004; DTR Country-Wide v Refill Rx, 1st Dept 2023), the defense is not precluded by an untimely denial (Presbyterian Hosp. v General Acc., 2d Dept 1996; NY & Presbyt. v Allstate, 2d Dept 2004, followed by both Appellate Terms), and an arbitration award beyond the limit exceeds the arbitrator's power (Brijmohan, Court of Appeals 1998). Under 11 NYCRR 65-3.15 'claims' means fully verified claims (Nyack Hosp. v GMAC, Court of Appeals 2007), so payments made while this claim was awaiting verification count. What divides the courts is a claim that was complete and DENIED before the limit ran out: the Appellate Term, Second Department (Alleviation 2017; First Am. Alliance 2018; S.O.V. 2020; North Queens 2025) holds that fully verified claims are payable in the order received, so later payments to other providers do not exhaust the policy as against the denied claim, and requires the insurer to show the dates each claim was received and verified; the Appellate Term, First Department (Harmonic 2015; Northeast Anesthesia 2016; Branch Med. 2022) holds the insurer may pay other legitimate claims after denying the plaintiff's and rely on exhaustion, and the Appellate Division, First Department (New Millennium v Progressive 2023; New Millennium v Garrison and Lam Quan 2024) holds that an arbitrator following Harmonic rather than Alleviation is not reversible and that an award after exhaustion exceeds the arbitrator's power. The Appellate Division, Second Department affirmed Alleviation on different grounds (2021, admissibility of the insurer's proof) and has not ruled on the priority point; its 2006 Montefiore and 2011 Mount Sinai decisions apply Nyack v GMAC to payments made during verification. The Third and Fourth Departments have no decision in the database.

Scope. Deciding this question means ruling on the insurer's defense that it owes nothing (or less) on the claim, judgment or award because it has already paid out the no-fault limit of the policy: the $50,000 basic economic loss limit, an optional/additional PIP limit, or the lower limit of an out-of-state policy. It covers whether the insurer's proof (affidavit, declarations page, payment log/ledger laying a business-record foundation, dates of receipt, verification and payment) established exhaustion; whether the exhausting payments were made in the order 11 NYCRR 65-3.15 requires, including whether only fully verified claims count (Nyack Hosp. v General Motors Acceptance Corp., Court of Appeals 2007) and whether an insurer that denied this claim may pay later claims and then rely on exhaustion (the Harmonic, App Term 1st Dept 2015 / Alleviation, App Term 2d Dept 2017 split); and whether the defense is available at all at that stage (it is not precluded by an untimely or missing denial; whether it can be raised after judgment, first on an article 75 petition, or after failing to raise it at trial). It also covers article 75 review of arbitration awards that granted a claim beyond the exhausted limit (excess of power, Brijmohan) or denied it on exhaustion.

Based on 84 decisions in our database, the most recent decided May 15, 2026.

Leading authorities · Governing regulations · Authority map · Decisions by court · Plain-text version (Markdown)

Leading authorities

New York & Presbyt. Hosp. v Allstate Ins. Co. (2004 NY Slip Op 08669) Appellate Division, Second Department, 2004Untimely denial does not preclude the exhaustion defenseReversing summary judgment for the hospital, the court held that the insurer's evidence raised issues of fact whether it had partially exhausted the policy by other no-fault payments made in compliance with 11 NYCRR 65.15 (n), and that its failure to deny within 30 days did not preclude the exhaustion defense.
The defendant’s failure to issue a denial of the claim within 30 days does not “preclude a defense that the coverage limits of the subject policy have been exhausted”
Alleviation Med. Servs., P.C. v Allstate Ins. Co. (2021 NY Slip Op 08159) Appellate Division, Second Department, 2021Exhaustion needs admissible proof; verified claims follow 65-3.15An insurer need not pay once the limits are exhausted and verified claims are subject to 11 NYCRR 65-3.15, but the insurer's employee affidavit, describing a claim file not in evidence and lacking any information about this claim, did not establish exhaustion; issues of fact remained. Affirmed the Appellate Term on different grounds without reaching its priority rule.
While the defendant submitted records indicating that the subject no-fault policy had been exhausted in 2013, the defendant’s submissions failed to establish its prima facie entitlement to judgment as a matter of law.
Later history: Affirms Alleviation Med. Servs., P.C. v Allstate Ins. Co., 55 Misc 3d 44 (App Term, 2d Dept 2017) (post 4534), 'albeit on different grounds'
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 02731) Appellate Division, Second Department, 2006What proves exhaustion: affidavits, denials, payment log, 65-3.15 orderThe insurer was entitled to summary judgment dismissing the hospital's claim because its claims representatives' affidavits, the denial forms and its payment log showed it exhausted the coverage limits before it became obligated to pay the claim, in compliance with 11 NYCRR 65-3.15.
its payment [*2]log listing all payments made to other healthcare providers under the subject policy, that it had exhausted the policy’s coverage limits before it became obligated to pay the hospital’s claim and that such payments were made in compliance with 11 NYCRR 65-3.15
Matter of New Millennium Pain & Spine Medicine, P.C. v Progressive Cas. Ins. Co. (2023 NY Slip Op 05369) Appellate Division, First Department, 2023First Department: arbitrator may follow Harmonic; no award after exhaustionWhere the provider conceded the policy was exhausted but argued that its claim, submitted and denied before exhaustion, kept priority, the arbitrator's choice to follow Harmonic (App Term 1st) rather than Alleviation (App Term 2d) did not warrant vacatur; an award after exhaustion would exceed the arbitrator's power (DTR Country-Wide v Refill Rx).
To the contrary, this Court has held that, in awarding a claim after a policy has been exhausted, an arbitrator exceeded his or her power since an insurer’s duties cease upon the insurer’s payment of the contractual limit on its no-fault policy
Alleviation Med. Servs., P.C. v Allstate Ins. Co. (2017 NY Slip Op 27097) Appellate Term, Second Department, 2017Second Department: denied claim keeps priority over later paymentsReading Nyack Hosp. v GMAC to hold that fully verified claims are payable in the order received, the court held that an insurer that denied the claim (so treating it as verified) could not rely on exhaustion by payments of other claims made after the denial; the defense was not precluded but failed, expressly disagreeing with Harmonic.
In contrast, in the instant case, by denying the claim on May 10, 2011, defendant implicitly declared that the claim at issue was fully verified. As we read Nyack Hosp. to hold that fully verified claims are payable in the order they are received
Later history: Affirmed on different grounds, 191 AD3d 934 (2d Dept 2021) (post 2283)
Harmonic Physical Therapy, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50525(U)) Appellate Term, First Department, 2015First Department: insurer may pay later claims after a denialThe insurer established that, after timely denying the plaintiff's claim for lack of medical necessity, the limits were exhausted by paying other providers' arbitration awards in compliance with 11 NYCRR 65-3.15, and 65-3.15 did not bar paying those claims while the plaintiff's disputed claim was pending; complaint dismissed.
Contrary to plaintiff’s contention, defendant was not precluded by 11 NYCRR 65-3.15 from paying other providers’ legitimate claims subsequent to the denial of plaintiff’s claims.
Nyack Hosp. v General Motors Acceptance Corp. 8 NY3d 294Leading case on 11 NYCRR 65-3.15: 'claims' means fully verified claims, so an insurer need not hold funds for claims awaiting verification and may pay verified claims as they come; cited by every later priority decision. Affirmed as modified 27 AD3d 96 (2d Dept 2005).Not in our database.
Matter of Brijmohan v State Farm Ins. Co. 92 NY2d 821An arbitration award beyond the policy limits exceeds the arbitrator's power (CPLR 7511 [b] [1] [iii]); the objection is not waived if raised in opposition to confirmation.Not in our database.
Presbyterian Hosp. in City of N.Y. v Liberty Mut. Ins. Co. 216 AD2d 448Source of the rule that once an insurer has paid the full monetary limits of the policy its duties under the contract cease.Not in our database.
Presbyterian Hosp. in City of N.Y. v General Acc. Ins. Co. of Am. 229 AD2d 479Failure to deny within 30 days does not preclude the defense that the coverage limits have been exhausted.Not in our database.
Countrywide Ins. Co. v Sawh 272 AD2d 245First Department statement that the insurer's duties cease once it has paid the full monetary limits; basis for vacating awards beyond the limit.Not in our database.
Nyack Hosp. v General Motors Acceptance Corp. 27 AD3d 96Second Department decision affirmed as modified by the Court of Appeals; cited (e.g. Montefiore 2006, NY & Presbyt. v Allstate 2006) for paying other providers properly before the plaintiff under 65-3.15.Not in our database.

Governing regulations

11 NYCRR 65-3.15 Once claims exceed $50,000, basic economic loss is paid in the order services were rendered, for claims made before the limit is exhausted; claims received after the limit is paid are not owed. The Court of Appeals reads 'claims' as fully verified claims.
11 NYCRR 65-1.1 (d) (Basic Economic Loss) Basic economic loss of each eligible injured person for any single accident may not exceed $50,000 (the death benefit apart): the limit whose exhaustion ends the insurer's duty to pay.

Also relevant

Chosen by us from the regulation text and the decisions on this question that cite it. Each link opens our copy of the regulation, which is unofficial; the official text is in the NYCRR.

Authority map

Each circle is a decision on this question, placed by court and date; its colour is the position it took. Lines are citations between them. Select a circle (or find a decision by name) to see its links and summary. The same decisions are listed by court below the map.

Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedExhaustion defense fails on the law or the insurer's own records: coverage remained when this claim became payableInsurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordExhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseCourt refuses to consider exhaustion on the merits for a procedural reasonRing: rules on the question, but another ground decided the caseContrasted, distinguished or limitedDeclined to follow, questioned, overruled or reversedCited Show ordinary citations

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How the rule was applied, by court

Court	Limits exhausted	Coverage left when due	Exhaustion not proved	Triable issue / hearing	Defense not heard	Total
Appellate Division, First Department	5	0	0	1	0	6
Appellate Division, Second Department	8	1	1	5	2	17
Appellate Term, First Department	2	0	0	7	0	9
Appellate Term, Second Department	6	4	28	4	0	42
Trial courts in the First Department	0	0	0	0	1	1
Trial courts in the Second Department	3	0	5	0	1	9

Decisions (84)

Every decision in our database that rules on this question: highest court first, then by department, newest first. 69 turn on it; the others rule on it alongside a different main ground (marked "also decides"). The one-sentence summaries describe what each court said on this question.

Appellate Division, First Department (6 decisions)

Matter of New Millennium Pain & Spine Medicine, P.C. v Garrison Prop. & Cas. Ins. Co. (2024 NY Slip Op 00599) Appellate Division, First Department, February 6, 2024Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedUpheld master awards denying the claims on exhaustion because following Harmonic rather than Alleviation was not irrational, an award after exhaustion would exceed the arbitrator's power, and the 20% wage offset against the limit was statutorily allowed.
Matter of Lam Quan, MD, PC v GEICO Gen. Ins. Co. (2024 NY Slip Op 00174) Appellate Division, First Department, January 16, 2024Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedUpheld an award denying the claim after the policy was exhausted. The arbitrator could follow Harmonic's rule allowing payment of later claims, an award after exhaustion would exceed the arbitrator's power, and the wage-offset argument failed.
Matter of New Millennium Pain & Spine Medicine, P.C. v Progressive Cas. Ins. Co. (2023 NY Slip Op 05369) Leading case Appellate Division, First Department, October 24, 2023Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedUpheld the award denying the claim where the policy was conceded exhausted, rejecting the argument that a claim denied before exhaustion keeps priority, because an insurer's duties cease once it pays the policy limit.
Matter of DTR Country-Wide Ins. Co. v Refill Rx Pharm., Inc. (2023 NY Slip Op 00179) Appellate Division, First Department, January 17, 2023Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer's supervisor affidavit and payment ledger showed the $50,000 policy was properly exhausted under 65-3.15 before the arbitration, so the award was vacated.
Country-Wide Ins. Co. v Metro Pain Specialists P.C. (2022 NY Slip Op 06865) Appellate Division, First Department, December 1, 2022Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer proved exhaustion through its declarations page, a claim supervisor's affidavit laying a business-record foundation, and a ledger showing $50,000 paid, and needed no 65-3.15 compliance showing because defendants never pleaded that defense.
Matter of Ameriprise Ins. Co. v Kensington Radiology Group, P.C. (2020 NY Slip Op 00500) Appellate Division, First Department, January 23, 2020Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseRejected the provider's claim of priority because its claims were never verified after its EUO no-show, and affirmed the remand for a framed-issue hearing on whether exhaustion preceded the insurer's obligation to pay.

Appellate Division, Second Department (17 decisions)

Matter of Fill Rx NY, Inc. v LM Gen. Ins. Co. (2025 NY Slip Op 04785) Appellate Division, Second Department, August 27, 2025Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedUpheld as having evidentiary support and a rational basis the arbitral finding that the policy's no-fault limits were exhausted, so the provider's claim was denied in full.
Alleviation Med. Servs., P.C. v Allstate Ins. Co. (2021 NY Slip Op 08159) Leading case Appellate Division, Second Department, February 24, 2021Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld the insurer failed to establish exhaustion because its employee's affidavit gave no information about this claim and described a claim file not in evidence, leaving unproven when and how the claim was denied relative to the exhausting payments.
Matter of Acuhealth Acupuncture, P.C. v New York City Tr. Auth. (2018 NY Slip Op 08641) Appellate Division, Second Department, December 19, 2018Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedUpheld as rational the arbitral finding that the policy had been exhausted when the last bill was received, so awarding benefits beyond the contractual limits would have exceeded the arbitrator's authority.
Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 05680) Appellate Division, Second Department, June 28, 2011Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld the insurer raised triable issues of fact whether the policy limits were exhausted by paying claims for prior services while its 30-day period on this claim was tolled by a pending verification request, defeating the hospital's summary judgment.
Westchester Med. Ctr. v Lincoln Gen. Ins. Co. (2011 NY Slip Op 02379) Appellate Division, Second Department, March 22, 2011Court refuses to consider exhaustion on the merits for a procedural reasonHeld the insurer could not cut down the judgment for exhaustion because it raised the policy limit only after judgment, its evidence was not newly discovered under CPLR 5015 (a) (2), and interest-of-justice relief was unwarranted.
Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 01008) Appellate Division, Second Department, February 8, 2011Court refuses to consider exhaustion on the merits for a procedural reasonHeld the insurer could not use CPLR 5019 (a) to reduce the judgment on the belated ground that the policy limits were nearly exhausted, because that motion corrects only clerical errors, not substantive matters.
St. Barnabas Hosp. v Country Wide Ins. Co. (2010 NY Slip Op 09121) Appellate Division, Second Department, December 7, 2010Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedUpheld reducing the judgment to account for partial exhaustion of the policy limits by payments to other providers, holding the insurer was not collaterally estopped because the summary judgment decided only timeliness and verification.
Westchester Med. Ctr. v Philadelphia Indem. Ins. Co. (2010 NY Slip Op 00138) Appellate Division, Second Department, January 5, 2010Exhaustion defense fails on the law or the insurer's own records: coverage remained when this claim became payable (also decides)In denying vacatur of the insurer's default, found that by the insurer's own records sufficient funds remained under the policy to pay the bill when it was received, so no meritorious defense was shown.

Show all 17 decisions

Montefiore Med. Ctr. v Government Empls. Ins. Co. (2006 NY Slip Op 08953) Appellate Division, Second Department, November 28, 2006Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld that, although the insurer's admissible proof showed other providers were properly paid first under 65-3.15, a triable issue existed on exhaustion because its own payment register showed a balance exceeding the amount billed.
Mount Sinai Hosp. v Allstate Ins. Co. (2006 NY Slip Op 03060) Appellate Division, Second Department, April 25, 2006Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer established entitlement to summary judgment dismissing the first cause of action because the policy limits had been exhausted, and the hospitals failed to raise a triable issue of fact.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 02731) Leading case Appellate Division, Second Department, April 11, 2006Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer's claims representatives' affidavits, denial forms and payment log showed the coverage limits were exhausted, by payments made in compliance with 65-3.15, before it became obligated to pay the hospital's claim.
Hospital for Joint Diseases v Hertz Corp. (2005 NY Slip Op 07932) Appellate Division, Second Department, October 24, 2005Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the judgment properly reduced and deemed satisfied because the insurer showed its payments to other providers and plaintiff, plus remitting the balance, exhausted the $50,000 limit, and it was not collaterally estopped from raising exhaustion.
New York & Presbyt. Hosp. v Government Empls. Ins. Co. (2005 NY Slip Op 02813) Appellate Division, Second Department, April 11, 2005Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld a triable issue existed whether the insurer's later payments to other providers exhausted the limit as against the hospital, because evidence that the claim arrived after the first verification request raised an issue whether that request was a nullity.
Mount Sinai Hosp. v Zurich Am. Ins. Co. (2005 NY Slip Op 01329) Appellate Division, Second Department, February 22, 2005Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld summary judgment for the hospital properly denied because the insurer raised issues of fact whether other no-fault payments exhausted the coverage limits and whether those payments complied with 11 NYCRR 65.15 (n).
New York & Presbyt. Hosp. v Allstate Ins. Co. (2004 NY Slip Op 08669) Leading case Appellate Division, Second Department, November 22, 2004Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld issues of fact existed whether the insurer partially exhausted the limits by other payments made in compliance with 11 NYCRR 65.15 (n), and that its failure to deny within 30 days did not preclude the exhaustion defense.
Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 05413) Appellate Division, Second Department, June 21, 2004Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer's evidence established that the PIP limits had been exhausted by prior claims, so its duties under the policy ceased and the hospital's cause of action was dismissed.
New York & Presbyt. Hosp. v Progressive Cas. Ins. Co. (2004 NY Slip Op 01750) Appellate Division, Second Department, March 15, 2004Insurer proved the limits were used up before it had to pay this claim; claim fails or is reduced (also decides)Held the insurer showed as a matter of law that it had paid the claim up to the applicable policy limits, so it was not obligated to pay the claim in full and that cause of action was dismissed.

Appellate Term, First Department (9 decisions)

Advantage Radiology, P.C. v MVAIC (2023 NY Slip Op 50139(U)) Appellate Term, First Department, February 27, 2023Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld the insurer's own submissions raised triable issues whether it exhausted the coverage limits through payments to other providers and the assignor's lost wages, and whether those payments complied with 65-3.15.
Allstate Fire & Cas. Ins. Co. v Branch Med., P.C. (2022 NY Slip Op 50277(U)) Appellate Term, First Department, April 19, 2022Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer proved exhaustion at the framed-issue hearing through adjuster testimony, declarations page and chronological payment ledgers, and that 65-3.15 allowed paying other legitimate claims after denying this one.
Ameriprise Ins. Co. v Kensington Radiology Group, P.C. (2017 NY Slip Op 51911(U)) Appellate Term, First Department, December 22, 2017Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld the insurer's attorney affirmation, declaration page and chronological payment ledger raised triable issues whether the $50,000 limit was exhausted before it became obligated to pay the claims, noting the defense survives a missing timely denial; framed-issue hearing ordered.
Easy Care Acupuncture, PC v MVAIC (2017 NY Slip Op 51346(U)) Appellate Term, First Department, October 11, 2017Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defense (also decides)Held the parties' submissions raised triable issues whether the insurer partially exhausted coverage by payments to another provider and whether those payments were proper under the regulations, and that an untimely denial did not preclude the defense.
Easy Care Acupuncture, PC v MVAIC (2016 NY Slip Op 51556(U)) Appellate Term, First Department, October 26, 2016Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defense (also decides)Held the insurer's own submission raised triable issues whether it partially exhausted coverage by payments to another provider and whether those payments complied with the regulations, and that the untimely denial did not preclude the defense.
Allstate Prop. & Cas. Ins. Co. v Northeast Anesthesia & Pain Mgt. (2016 NY Slip Op 50828(U)) Appellate Term, First Department, May 31, 2016Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld the declaration page and chronological payment ledger raised triable issues on exhaustion before the insurer was obligated to pay, and that 65-3.15 did not bar paying other legitimate claims after denying this one; framed-issue hearing ordered.
Harmonic Physical Therapy, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50525(U)) Leading case Appellate Term, First Department, April 14, 2015Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedHeld the insurer established that, after timely denying the claim, the limits were exhausted by paying other providers' arbitration awards in compliance with 65-3.15, which did not bar paying legitimate claims while the disputed claim was pending.
Allstate Ins. Co. v DeMoura (2011 NY Slip Op 50430(U)) Appellate Term, First Department, March 24, 2011Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defenseHeld the insurer's submissions raised a triable issue whether the $50,000 limit was exhausted under 65-3.15 before payment could be made on the claim, the defense surviving the lack of a timely denial; framed-issue hearing ordered.

Show all 9 decisions

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Appellate Term, Second Department (42 decisions)

Big Apple Delivery Supply Corp. v Plymouth Rock Assur. Corp. of N.Y. (2026 NY Slip Op 50794(U)) Appellate Term, Second Department, May 15, 2026Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defense (also decides)Held that the insurer's failure to timely deny did not preclude its exhaustion defense, and remitted the unaddressed exhaustion branch of its summary judgment motion for determination after rejecting the medical-necessity ground.
Big Apple Delivery Supply Corp. v Plymouth Rock Assur. Corp. of N.Y. (2026 NY Slip Op 50795(U)) Appellate Term, Second Department, May 15, 2026Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defense (also decides)Held that the failure to deny within 30 days did not preclude the exhaustion defense and remitted the unaddressed exhaustion branch of the insurer's summary judgment motion for determination.
Acupuncture Now, P.C. v MVAIC (2026 NY Slip Op 50196(U)) Appellate Term, Second Department, January 23, 2026Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld the insurer failed to prove exhaustion under 65-3.15 because it did not set forth the dates on which it received the various claims and on which they became fully verified.
Healthway Med. Care, P.C. v MVAIC (2026 NY Slip Op 50200(U)) Appellate Term, Second Department, January 23, 2026Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld that the admissible payment log did not show when the various claims were received and became fully verified, so the insurer failed to prove exhaustion under 65-3.15 for the five causes of action it targeted.
Healthway Med. Care, P.C. v MVAIC (2026 NY Slip Op 50199(U)) Appellate Term, Second Department, January 23, 2026Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld that, although the payment log was admissible as a business record, it omitted the dates claims were received and became fully verified, so exhaustion in accordance with 65-3.15 was not established as a matter of law.
Acupuncture Now, P.C. v MVAIC (2026 NY Slip Op 50197(U)) Appellate Term, Second Department, January 23, 2026Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld that the admissible payment log omitted the dates claims were received and fully verified, so the insurer did not establish exhaustion in accordance with 65-3.15 as a matter of law.
Healthway Med. Care, P.C. v MVAIC (2026 NY Slip Op 50198(U)) Appellate Term, Second Department, January 23, 2026Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld that the payment log, though admissible, did not show the dates claims were received and became fully verified, so the insurer failed to establish exhaustion under 65-3.15 and its motion was properly denied.
Chiropractic Assoc. of Richmond Hill, P.C. v Nationwide Gen. Ins. Co. (2025 NY Slip Op 50506(U)) Appellate Term, Second Department, April 4, 2025Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld the insurer not entitled to summary judgment on its exhaustion defense because it failed to show, as a matter of law, that the policy limits were exhausted under 65-3.15 before the provider's completed claims were received.

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Trial courts in the First Department (1 decision)

Breeze Acupuncture, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50138(U)) Civil Court of the City of New York, Bronx County, February 1, 2018Court refuses to consider exhaustion on the merits for a procedural reasonDenied the insurer's post-judgment motion to reduce the judgment to zero because it knew the policy was exhausted years before trial yet never raised the defense at trial, so it waived exhaustion.

Trial courts in the Second Department (9 decisions)

334 Grand Concourse Med., P.C. v Plymouth Rock Assur. (2026 NY Slip Op 50539(U)) Civil Court of the City of New York, Kings County, April 15, 2026Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this record (also decides)Held the insurer failed to raise a triable issue on exhaustion because no affiant with knowledge of its record-keeping laid a business-record foundation for the policy, its limits, or the exhaustion ledger.
Stark Med. Supply Inc. v Foremost Prop. & Cas. Ins. (2024 NY Slip Op 50002(U)) Civil Court of the City of New York, Kings County, January 8, 2024Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordHeld after trial that the insurer failed to prove exhaustion because its payment log carried erroneous dates and nothing beyond the witness's testimony showed the exhausting payment preceded the claim when it was complete.
American Tr. Ins. Co. v Trinity Pain Mgt. of Staten Is., PLLC (2023 NY Slip Op 51337(U)) Supreme Court, Kings County, December 8, 2023Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordUpheld the arbitral finding that the insurer failed to prove exhaustion because it submitted only a bare payment ledger, so the award requiring payment was not beyond the arbitrator's power.
Matter of Spartan Med. Supply v Liberty Mut. Ins. Co. (2019 NY Slip Op 50862(U)) District Court of Nassau County, June 3, 2019Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedConfirmed the award upholding the insurer's exhaustion denial, holding that applying Harmonic, which allows exhaustion by later payments after a good-faith denial of the claim, was not irrational.
Island Life Chiropractic Pain Care PLLC v Amica Mut. Ins. Co. (2019 NY Slip Op 51589(U)) Civil Court of the City of New York, Kings County, May 17, 2019Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this recordDenied the insurer's exhaustion-based summary judgment because its payment ledger lacked a CPLR 4518 business-record foundation, did not show when prior bills were received or paid, and did not show payments followed proper priority under 65-3.15.
All Healthy Style Med., P.C. v ELRAC, Inc. (2018 NY Slip Op 51333(U)) Civil Court of the City of New York, Kings County, May 16, 2018Insurer's proof did not establish exhaustion (or compliance with 65-3.15); defense fails on this record (also decides)Held the insurer failed to establish exhaustion when it received the bills because the ledger did not show when prior bills were received or paid and its ambiguous date headings were unexplained.
Ortho Passive Motion Inc. v Allstate Ins. Co. (2017 NY Slip Op 27057) District Court of Nassau County, Third District, March 1, 2017Court refuses to consider exhaustion on the merits for a procedural reasonDenied the insurer's post-judgment motion to modify the judgment to zero because it pleaded exhaustion, knew the limits were exhausted years before trial, but failed to raise or prove the defense at trial.
Acuhealth Acupuncture, P.C. v New York City Tr. Auth. (2016 NY Slip Op 50297(U)) Supreme Court, Kings County, March 1, 2016Insurer proved the limits were used up before it had to pay this claim; claim fails or is reducedConfirmed an award denying the claim because the policy was exhausted, holding that an award beyond the limits would exceed the arbitrator's power and that the provider's Nyack priority argument showed at most an unreviewable error of law.

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How this page is made: the decisions are those in our case-law database that cite this question's leading cases or were tagged with its subject. A language model read each one in full and recorded whether it rules on the question, the position it took and a one-sentence summary; a second, independent reading checked every entry. Court, department, date and the citation links come from the database. Read the decision before relying on it.