No-Fault Case Law

The court considered the procedural history of an arbitration decision where an arbitrator awarded Excell Clinical Lab $3,129.75 in No-Fault benefits related to a motor vehicle accident. American Transit Insurance Company sought to vacate the arbitration award, arguing that Excell had not established the medical necessity of the disputed services, as they failed to provide an Independent Medical Examination (IME) report or peer review evidence of their own. The key issues addressed included whether the arbitrators' decision was final and definite, as well as whether the award should be vacated under the grounds outlined in CPLR 7511(b). The court ultimately denied the petition to vacate the arbitration award, concluding that the arbitrators had made a rational decision based on the evidence presented and that the award was sufficiently final and definitive.

The court considered several relevant facts, including the procedural history of the case, which involved UGP Acupuncture, P.C. seeking reimbursement from Progressive Northern Insurance Company for medical services rendered following a motor vehicle accident. The initial action was settled between the parties, leading to a Stipulation of Settlement and Discontinuance which was executed on July 23, 2021, and resulted in the case being deemed disposed. The plaintiff then attempted to amend the complaint to substitute Country Wide Insurance Company as the new defendant, arguing that the original index number was preserved for this purpose. The court decided that the index number was extinguished as a result of the prior settlement, and since the motion to amend was moot, the court vacated its earlier interim order related to this motion. Ultimately, the court held that the motion to amend was deemed moot, affirming that the case had been properly settled and disposed of through the Stipulation of Settlement and Discontinuance.

In this case, the court considered the validity of the plaintiff's claims for no-fault benefits assigned by a patient after the defendant, an insurance company, sought summary judgment to dismiss the complaint. The main issues included whether the plaintiff provided sufficient verification of the claims and the procedural implications of an unrelated declaratory judgment action involving the same parties. The court determined that the affidavit from the plaintiff sufficiently demonstrated that verification had been mailed and received by the defendant, thus providing a presumption in favor of the plaintiff. Ultimately, the holding modified the previous order by denying the defendant's motion for summary judgment and affirming the case without costs, allowing the plaintiff's claims to proceed.

The court considered a case where a medical provider, as the assignee of a patient, sought to recover no-fault insurance benefits from Mid-Century Insurance Company. The main issues involved whether the insurance company had appropriately demonstrated that the policy limits were exhausted and if the provider was barred from recovering based on the fee schedule. The court found that the defendant's payment log did not meet the necessary evidentiary standards to prove that payments had been made to the provider for the claims in question. However, the court noted that the plaintiff's argument regarding the fee schedule was not preserved for appeal since it was raised for the first time on appeal. Ultimately, the order granting summary judgment in favor of the defendant was affirmed.

The court considered multiple instances where Respondents' attorneys pursued aggressive litigation tactics, including failure to issue satisfactions of judgment despite partial payments by Petitioner. It assessed the reasonableness of Petitioner's attorney fees at $210 per hour, totaling $1,470 for each proceeding, based on the complexity and time spent on each case. The main issue was whether Respondents' conduct warranted sanctions and attorney fees under CPLR 130-1.1, which the court granted, imposing $735 in fees against each attorney and daily sanctions of $10 for delays in issuing satisfactions of judgment, totaling $2,570 to $3,010 per case. The holding affirmed the awards of attorney fees and sanctions, emphasizing the excessive litigation tactics of Respondents' counsel.

In this case, Denar Balcazar sought to recover $2,101.17 from State Farm Insurance for medical services, while State Farm moved for summary judgment dismissing the case due to Balcazar's failure to appear for an examination under oath (EUO). The court examined whether State Farm properly requested the EUO and established a specific objective justification for it, ultimately finding that State Farm's scheduling letters did not provide sufficient specific justification related to Balcazar's claim. The court concluded that the defendant did not meet its burden of proof to warrant summary judgment. Conversely, the plaintiff's cross-motion for summary judgment was denied due to a lack of a party affidavit from someone with personal knowledge of the claim. Consequently, both motions were denied, and the case was scheduled for a pre-trial conference.

The court considered a case where a provider was seeking first-party no-fault benefits for services rendered after a motor vehicle accident, with the vehicle insured under a Florida automobile insurance policy. The insurer had claimed the policy was cancelled before the accident due to nonpayment of the premium, but the provider disputed this based on Florida law requirements for notice of cancellation. The issue was whether the insurer had provided sufficient proof of mailing the cancellation notice to the insured, as required by Florida law. The court held that the insurer's submitted Certificate of Bulk Mailing did not meet the requirements for proof of mailing under the statute, and therefore, the branch of the insurer's motion seeking to dismiss the complaint was denied.

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.