The Court of Appeals, deferring to DFS, held that 11 NYCRR 65-3.16 (a) (12) does not let an insurer deny reimbursement for alleged professional misconduct, such as paying for referrals, short of ceding control to an unlicensed party (GEICO v Mayzenberg). It distinguished Mallela and Carothers as foundational licensing violations and left open when kickbacks amount to such control. Four Second Department decisions let courts fix article 75 attorney's fees without a hearing nobody requested. Citing Hospital for Joint Diseases, the Appellate Term, First Department, held that a verification request one day late under 11 NYCRR 65-3.5 (b) only shortened the insurer's 30 days (Quazi R. Med. v Nationwide).
Our summary of the month’s decisions, not the courts’ words.
Court of Appeals
Nov 24, 2025
2025 NY Slip Op 06527
Provider prevailed
An insurer may not deny no-fault reimbursement for alleged professional misconduct short of ceding control to an unlicensed party. The Court of Appeals answered a certified question in the provider's favor after a federal court granted the insurer summary judgment declaring the provider ineligible because of paid patient referrals. Deferring to DFS's rational interpretation of 11 NYCRR 65-3.16 (a) (12), the majority distinguished foundational licensing requirements from professional discipline under Education Law § 6530 (18) and 8 NYCRR 29.1 (b) (3), which does not itself terminate licensure. The majority left open when a kickback scheme constitutes prohibited surrender of control; a dissent would permit denial for misconduct functionally equivalent to the defects in Mallela and Carothers.
Appellate Division, Second Department
Nov 26, 2025
2025 NY Slip Op 06604
Insurer prevailed
The insurer established nonliability for lost-wage benefits through unexplained inconsistencies in the claimant's financial records. In a de novo action under Insurance Law § 5106 (c), the insurer submitted an accountant's report, tax returns, a bankruptcy petition, and deposition testimony. The returns conflicted with each other and the bankruptcy petition; the claimant neither explained the discrepancies nor produced underlying business income records. Insurance Law § 5102 (a) (2) and 11 NYCRR 65-3.16 (b) (3) and (6) contemplate ascertainable earnings the claimant would have realized. The Appellate Division, Second Department, affirmed summary judgment declaring no lost-wage liability and dismissing the counterclaims. It also held that Insurance Law § 2601 creates no private action for unfair claims settlement practices; the insurer's remaining contention was not properly before it.
Appellate Division, Second Department
Nov 5, 2025
2025 NY Slip Op 06054
Insurer prevailed
The provider's $250 attorney's fee award was upheld because it submitted no supporting affidavit or affirmation and requested no hearing. After denying the insurer's petition to vacate and confirming the master arbitration award, the lower court fixed additional fees for the article 75 proceeding. The Appellate Division, Second Department, affirmed the judgment insofar as appealed from. Insurance Law § 5106 (a) and 11 NYCRR 65-4.10 (j) (4) authorize reasonable fees fixed by the adjudicating court. The attorney bore the burden of establishing reasonable hours and the prevailing community rate. Without a sworn description of the work and time spent, the court could determine a reasonable fee without a hearing; the provider's remaining contention was academic.
Appellate Division, Second Department
Nov 5, 2025
2025 NY Slip Op 06057
Insurer prevailed
The provider's $1,100 attorney's fee award was upheld based on the prevailing rate and the matter's complexity, without a requested hearing. After obtaining leave to seek a fee determination in the article 75 proceeding, the provider submitted counsel's affirmation claiming $4,550 for work performed. The Appellate Division, Second Department, affirmed the judgment insofar as appealed from. Insurance Law § 5106 (a) and 11 NYCRR 65-4.10 (j) (4) authorize reasonable fees fixed by the adjudicating court. Counsel bore the burden of establishing reasonable hours and the prevailing community rate. The absence of a hearing request and the no-fault law's prompt-resolution purpose permitted a determination without a hearing. The Supreme Court, Kings County, properly considered the prevailing rate and complexity in fixing the award.
Appellate Division, Second Department
Nov 5, 2025
2025 NY Slip Op 06056
Insurer prevailed
The benefits claimant's $500 attorney's fee award was upheld without a hearing because no sworn account of the work or hearing request was submitted. The Supreme Court, Kings County, denied the insurer's petition to vacate, confirmed the master arbitration award, and fixed additional fees for the article 75 proceeding. The Appellate Division, Second Department, affirmed the judgment insofar as appealed from. Insurance Law § 5106 (a) and 11 NYCRR 65-4.10 (j) (4) authorize reasonable fees fixed by the adjudicating court. Counsel must establish the reasonable hours expended and the prevailing community rate. Without an affidavit or affirmation describing the work and time spent, or a hearing request, the lower court could fix the fee without a hearing; the claimant's remaining contention was academic.
Appellate Division, Second Department
Nov 5, 2025
2025 NY Slip Op 06055
Insurer prevailed
The provider's $1,100 attorney's fee award was upheld based on the prevailing rate and the matter's complexity, without a requested hearing. The provider sought additional fees for representation in an article 75 proceeding and submitted counsel's affirmation claiming $4,450 for the work performed. The Appellate Division, Second Department, affirmed the judgment insofar as appealed from. Under Insurance Law § 5106 (a) and 11 NYCRR 65-4.10 (j) (4), the adjudicating court fixes reasonable fees, and counsel must establish reasonable hours and the prevailing community rate. Given the absence of a hearing request and the no-fault law's purpose of prompt resolution, no hearing was required. The Supreme Court, Kings County, acted within its discretion in considering the prevailing rate and complexity when fixing the award.
Appellate Term, First Department
Nov 24, 2025
2025 NY Slip Op 51853(U)
Insurer prevailed
The insurer established mailing of EUO scheduling letters and the provider's failure to appear at properly scheduled EUOs. The Appellate Term, First Department, reversed the order, denied the provider's cross-motion for summary judgment, and granted the insurer's motion dismissing the no-fault complaint. The insurer's attorney sufficiently described the office's standard mailing practices and procedures and represented under penalty of perjury, based on personal knowledge, that they were followed in this matter. That proof adequately established mailing to the provider; the court reached no other issue.
Appellate Term, First Department
Nov 21, 2025
2025 NY Slip Op 51848(U)
Insurer prevailed
The insurer established mailing of EUO scheduling letters and the provider's failure to appear at properly scheduled EUOs. The Appellate Term, First Department, reversed the order denying the insurer's unopposed summary judgment motion, granted the motion, and dismissed the provider's no-fault complaint. The insurer's attorney described the office's standard mailing practices and procedures and represented under penalty of perjury, based on personal knowledge, that those procedures were followed in this matter. That showing adequately proved mailing to the provider.
Appellate Term, First Department
Nov 13, 2025
2025 NY Slip Op 51784(U)
Insurer prevailed
The insurer's EUO request, sent one day after the 15-day deadline but before the 30-day denial window expired, remained valid. The Appellate Term, First Department, reversed the order denying the insurer's unopposed summary judgment motion, granted the motion, and dismissed the provider's no-fault complaint. The insurer made a prima facie showing that the provider failed to appear at properly scheduled EUOs. Contrary to the lower court's conclusion, the verification request's one-day delay beyond the period in 11 NYCRR 65-3.5 (b) did not invalidate the request; it merely reduced the insurer's 30-day period to pay or deny the claim.
Appellate Term, Second Department
Nov 7, 2025
2025 NY Slip Op 51833(U)
Insurer prevailed
The insurer's employee affidavits supported a presumption that the EUO scheduling letters and denial forms were timely mailed. The provider sought assigned no-fault benefits, and the insurer moved for summary judgment based on the assignor's failure to attend duly scheduled EUOs. Rejecting the provider's challenge to the mailing proof, the Appellate Term, Second Department, affirmed the order granting the insurer's motion to dismiss the complaint and denying the provider's cross motion for summary judgment.
Appellate Term, Second Department
Nov 7, 2025
2025 NY Slip Op 51832(U)
Provider prevailed
The insurer failed to prove nonreceipt of the claims because its affidavit did not establish incoming-mail practices and procedures. In the provider's action for assigned no-fault benefits, the insurer sought summary judgment dismissing the complaint on that ground. Its litigation specialist's affidavit did not establish the insurer's procedures for receiving and processing incoming mail. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, leaving that branch of the insurer's motion denied.
