No-Fault Case Law

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 the defendant's motion for summary judgment dismissing the complaint on the grounds that the plaintiff's assignor was not an eligible injured person (EIP) for receipt of no-fault benefits as his injuries did not arise from the use or operation of an insured vehicle. The defendant contended that the injuries were the result of an assault after the motor vehicle accident. However, the court found that the defendant failed to establish, as a matter of law, that the plaintiff's assignor was not an eligible injured person as defined by the Insurance Law and no-fault regulations. The hospital records relied upon by the defendant were not admissible as they were not certified and the defendant failed to 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 dismissing the complaint, as the motion failed to eliminate all material questions of fact as to whether the injuries were the result of an assault and not the result of the use or operation of a motor vehicle. Therefore, the order denying the defendant's motion for summary judgment was affirmed.

The court considered the defendant's motion seeking summary judgment dismissing claims for services rendered from June 8, 2020 through July 7, 2020 and from July 14, 2020 through October 5, 2020 on the ground that the plaintiff failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided was whether the defendant was entitled to summary judgment dismissing the claims for services rendered due to the plaintiff's failure to appear for the scheduled EUOs. The holding of the court was that the defendant was entitled to summary judgment dismissing the claims for services rendered from the specified time periods as the plaintiff failed to appear for the scheduled EUOs and did not raise a triable issue of fact in response to the defendant's prima facie showing.

The court considered the fact that the defendant had denied the claims on the ground that the plaintiff failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided was whether the defendant had established its prima facie entitlement to summary judgment by providing evidence of timely mailing of the EUO scheduling letters and denial of claim forms, as well as affidavits and certified transcripts of nonappearances. The holding of the case was that defendant had indeed established its prima facie entitlement to summary judgment, and therefore the order denying defendant's motion for summary judgment dismissing the complaint was reversed, and the motion was granted. The court found that plaintiff had failed to raise a triable issue of fact in opposition to defendant's motion, and as a result, defendant's motion for summary judgment dismissing the complaint should have been granted.

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.

The court considered the fact that the defendant in the case was personally served with process at its Illinois office on September 29, 2020, and that they did not timely appear or answer the complaint. The defendant later contacted the plaintiff's counsel to request that the action be voluntarily discontinued, arguing that there was no coverage under the insurance policy. The main issue decided in the case was whether the defendant had a reasonable excuse for its delay in answering the complaint. The holding of the case was that the Civil Court granted the defendant's motion to compel the plaintiff to accept its late answer, finding that the defendant had proffered a reasonable excuse for its delay in serving its answer. The court found that the defendant's lack of willfulness and the absence of prejudice to the plaintiff justified the decision.

State Farm Mutual Automobile Insurance Company sought to recover damages for unjust enrichment. The company had provided payments for medical services on behalf of individuals who had been injured in a motor vehicle accident while traveling in a vehicle insured by State Farm. It was discovered that the injured individuals had applied for and been directed to receive workers' compensation benefits by a different insurer. State Farm demanded that the defendant reimburse it for the full amount of no-fault benefits paid out. The Supreme Court initially granted the defendant's motion to dismiss the complaint, arguing that the Workers' Compensation Board had primary jurisdiction over the coverage dispute. However, the Appellate Division reversed this decision, stating that the matter should be referred to the Workers' Compensation Board.