No-Fault Case Law

The main issue in this case was whether a No-Fault insurance arbitration determination should be vacated where the hearing arbitrator found that the respective bill was mailed past the 45-day deadline for submitting proof of claim due to a lack of an affidavit describing mailing procedures or confirming the actual mailing of the bill. Petitioner's sole evidence on the issue was a USPS certificate of mailing found to contain an illegible postmark. The court considered the arbitration award, the submissions from both parties, and relevant case law in making its decision. The court held that the No-Fault insurance arbitration determination should be vacated based on the lack of sufficient evidence supporting the mailing of the bill. This was made in consideration of the specific procedures and deadlines outlined in the relevant state law and regulations.

The court considered the fact that the plaintiff had already filed a summons and complaint and an amended summons and amended complaint, and that the defendant failed to answer, appear, or otherwise respond to the amended complaint. The court also considered the unsworn statement submitted by the plaintiff, which was found to satisfy the requirements of CPLR 2106 as amended. The main issue decided was whether the plaintiff was entitled to a default judgment. The court held that the plaintiff was entitled to a default judgment, as the plaintiff had shown prima facie good service of process, the defendant had failed to respond, and the unsworn statement submitted by the plaintiff constituted adequate proof of the facts constituting the claims. Therefore, the court granted the motion for an order directing the entry of a default judgment in favor of the plaintiff and against defendant Shekima Roberts.

The case Burke Physical Therapy, P.C. v State Farm Mutual Automobile Insurance Co. involved an action by a provider to recover assigned first-party no-fault benefits. The insurance company defendant had denied the claims based on the plaintiff's failure to timely provide the requested written verification. The main issue in the case was whether the insurance company had timely denied the claims at issue. The court held that the insurance company did not demonstrate that it timely denied the claims and therefore was not precluded from raising the defense upon which its motion for summary judgment was based. As a result, the court modified the order by denying the defendant's motion for summary judgment dismissing the complaint, and also denied the plaintiff's cross-motion for summary judgment. This decision was made by the Appellate Term, Second Department on March 15, 2024.

The court considered whether the plaintiff's assignor was an eligible injured person (EIP) for receipt of no-fault benefits after sustaining injuries in a motor vehicle accident. Defendant moved for the summary judgment dismissing the complaint, arguing that the assignor's injuries did not arise from the use or operation of an insured vehicle, but were due to an assault after the accident. The court found that the defendant failed to establish, as a matter of law, that the assignor was not an EIP and that the hospital records relied upon by the defendant were not admissible as they were not certified and the defendant did not establish a proper foundation for their admissibility. Even if the hospital records and the statements contained therein were admissible, the defendant would still not be entitled to summary judgment as their motion failed to eliminate all material questions of fact as to the assignor's injuries. Therefore, the order denying the defendant's motion for summary judgment was affirmed.

The main issue in this case was whether the plaintiff was entitled to recover first-party no-fault benefits for services rendered when they failed to appear for scheduled examinations under oath (EUOs). The court considered the fact that defendant established prima facie evidence that they had timely scheduled the EUOs, that the plaintiff had failed to appear for the scheduled EUOs, and that the defendant had issued timely and proper denials of the claims following the plaintiff's failure to appear at the last scheduled EUO. The court also addressed that the plaintiff failed to raise a triable issue of fact in response to the defendant's prima facie showing. Ultimately, the court held that the defendant was entitled to summary judgment dismissing so much of the complaint as sought to recover upon those claims for services rendered from specific dates, as the plaintiff failed to appear for the duly scheduled examinations under oath.

The main issue in this case was whether the defendant, Nationwide Mutual Insurance Company, was entitled to summary judgment dismissing the complaint brought by GPLW Acupuncture, P.C., as the assignee of Claude Watson, seeking to recover first-party no-fault benefits. The court considered the evidence presented by the defendant, including the timely mailing of scheduling letters and denial of claim forms for examinations under oath (EUOs), as well as affidavits and certified transcripts of nonappearances. The court found that the defendant had established its prima facie entitlement to summary judgment. The court also addressed the plaintiff's argument about the convenience of the scheduled EUO location, noting that the scheduling letters offered a virtual appearance option. Ultimately, the court reversed the lower court's order and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the fact that the plaintiff, Primavera Physical Therapy, P.C., had filed a complaint against State Farm Insurance Company, seeking payment for No-Fault claims for an accident on September 5, 2017. The main issue the court decided on was whether the action was barred under the doctrines of res judicata and collateral estoppel by a Declaratory Judgment granted on default in the Supreme Court, County of Nassau, by State Farm Fire and Casualty Insurance Company v. Luis Alejandro, et. al. The court held that the action was indeed barred under the doctrines of res judicata and collateral estoppel, and therefore dismissed the plaintiff's complaint, stating that the court is mandated to take judicial notice of any Declaratory Judgment actions duly entered in courts of superior jurisdiction, whether brought to the court's attention or not.

The court considered the case of Matter of Floral Park Drugs, Inc., a pharmacy and assignee of a person injured in a motor vehicle accident, seeking coverage from Nationwide General Insurance Company for prescription drug services. Nationwide denied coverage based on evidence that Floral Park filled prescriptions that were not electronic, failing to comply with Public Health Law § 281. The main issue was whether Floral Park was entitled to coverage for prescription drug services. The holding of the court was that the denial of the petition to vacate the master arbitrator's award was affirmed, as the arbitrators' conclusions in denying Floral Park's claim were not irrational or contrary to settled law, and that they did not violate a strong public policy or exceed a specifically enumerated limitation on the arbitrators' powers. Therefore, the petition to vacate the award was denied.

The court considered the fact that JSJ Anesthesia Pain Management, PLLC was seeking to recover assigned first-party no-fault benefits from Nationwide Insurance Company. The main issue decided was whether defendant had proven that they had paid the limits of the policy in accordance with 11 NYCRR 65-3.15. The holding was that defendant failed to prove, as a matter of law, that payments had been made, as the claim specialist did not lay a sufficient foundation for the payment log to be accepted as proof of payments. Therefore, defendant failed to show entitlement to summary judgment. Plaintiff's cross-motion for summary judgment was properly denied as well, as they also failed to establish that the claim had not been timely denied, or that defendant had issued a timely denial of claim form that was conclusory, vague, or without merit as a matter of law. As a result, the order granting defendant's motion for summary judgment dismissing the complaint was modified to deny defendant's motion.

The court considered an appeal from an order granting the defendant's motion for summary judgment dismissing the complaint and denying the plaintiff's cross-motion for summary judgment in an action to recover assigned first-party no-fault benefits. The main issue decided was whether the policy limits had been exhausted and whether the defendant was entitled to summary judgment. The holding of the case was that the order was modified to provide that the defendant's motion for summary judgment dismissing the complaint was denied, and as so modified, the order was affirmed without costs. This decision was based on the reasoning stated in a related case.