No-Fault Case Law

The relevant facts of the case involved an action by a provider to recover assigned first-party no-fault benefits. The defendant filed a motion to dismiss the complaint under the statute of limitations, arguing that the action was time-barred. The main issue decided by the court was whether the action was timely and whether the defendant's motion to dismiss was properly granted. The holding of the court was that the defendant did not establish that the action was untimely with respect to certain claims, and therefore the order was modified to deny the motion to dismiss for those specific claims. The court found that defendant did not meet its initial burden of demonstrating that those claims were untimely and that the action was barred by the statute of limitations. The court also did not accept plaintiff's argument that the defendant had failed to lay a proper foundation for the exhibits attached to its motion papers. The dissenting opinion, on the other hand, disagreed with the majority's determination and argued that there was sufficient proof to warrant a finding that the statute of limitations had expired on all claims submitted by the plaintiff.

The court considered a situation in which plaintiff's motion for summary judgment had been granted by the Civil Court and plaintiff had been awarded the principal amount, statutory interest and attorney's fees. The judgment had been entered on November 21, 2008. Defendant subsequently moved to vacate the judgment, arguing that plaintiff was not entitled to the full amount of the judgment because the interest had been improperly calculated. Defendant contended that interest on the claim should only have been calculated from the date the action was commenced on October 5, 2005, while plaintiff computed interest from 30 days after defendant's receipt of the claim forms. The main issue considered by the court was whether the interest on the claims at issue should commence 30 days after defendant's receipt of the claim forms or from the date the claim was presented to the defendant for payment. The holding was that plaintiff's calculations of interest were in error and the order was reversed, defendant's motion was denied and the judgment was reinstated.

The court considered the motion for summary judgment by the defendant, Travelers Property Casualty Ins. Co., in a case involving electro-diagnostic testing performed by Novacare Medical P.C. on an assignor, Winston J. Thorpe. The main issue decided was whether the submission of an affirmed peer review report is sufficient to shift the burden to the plaintiff to submit opposing expert proof in order to defeat an insurer's summary judgment motion. The court held that a conclusory unsubstantiated peer review report is not enough to meet the insurer's initial burden, and that the burden of submitting contrary evidentiary proof is not properly imposed on the opponent until the moving party meets its initial burden. The court also found that the defendant's proof of mailing of its denials was sufficient, and that its fee schedule defense was established, but that the issue of medical necessity would need to be tried.

The main issue in this case was whether the defendant, New York Central Mutual Fire Insurance Company, had provided sufficient evidence that it had mailed notices of independent medical examinations (IMEs) to the assignor, and whether the assignor's failure to attend the IMEs was justified. The court considered the defendant's documentary submissions, which established that the IME notices had been mailed to the assignor and that the assignor had failed to attend the IMEs. The plaintiff, Center for Orthopedic Surgery, LLP, failed to raise a triable issue regarding the reasonableness of the requests or the assignor's failure to attend the IMEs. Therefore, the court held that the defendant had proved the mailing of the IME notices, and the complaint was dismissed. The decision was reversed, and the motion was granted in favor of the defendant.

The court considered whether the insured decedent's injuries were caused by an accident within the meaning of the uninsured motorist endorsement and other provisions of the insured's policy. The main issue was whether the coverage of the policy was applicable to injuries caused by the intentional conduct of the operator of the vehicle. The holding of the court was that, viewed from the insured's perspective, the occurrence was an unexpected or unintended event and therefore an "accident" within the meaning of the policy, entitling the insured to benefits under the uninsured/underinsured motorist endorsement, mandatory personal injury protection endorsement, and death, dismemberment, and loss of sight endorsement of the policy. The court also held that the insured was entitled to coverage under the personal injury protection and death, dismemberment, and loss of sight endorsements of the policy.

The main issue in this case was whether or not the court should grant a permanent stay of arbitration following the denial of a claim for no-fault insurance benefits by the insurance company. The court considered whether the denial of benefits is a dispute involving the insurer's liability to pay first party benefits. The holding of the court was that the Supreme Court properly refused to grant a permanent stay of arbitration, and that the issue of whether the offset for workers' compensation benefits exceeds the monthly limit of first party benefits is a matter for arbitration. The court also rejected the petitioner's contention that it was denied its right to seek a loss-transfer claim from additional proposed respondents.

The court considered the fact that the petitioner (an insurance company) appealed from an order of the Civil Court which denied its petition to vacate an arbitration award in favor of the respondent, awarding him unpaid no-fault benefits in the principal sum of $11,170.42, and granted respondent's cross petition to confirm the arbitration award. The main issues were whether the $50,000 limit of the subject insurance policy was exhausted before the petitioner-insurer was obligated to pay respondent's claim, and whether the arbitrator's award directing payment in excess of the $50,000 limit of a no-fault insurance policy exceeds the arbitrator's power and constitutes grounds for vacatur of the award. The holding of the court was to reverse the order denying the petition to vacate the arbitration award, and remand the matter to Civil Court for a framed issue hearing regarding whether the $50,000 limit of the subject insurance policy was exhausted before the petitioner-insurer was obligated to pay respondent's claim.

The Court considered a case in which a hospital was seeking to recover no-fault medical benefits from an insurance company after being awarded a judgment in its favor. The defendant, an insurance company, sought to modify the judgment, claiming it exceeded the coverage limit of the policy due to payments previously made to other healthcare providers. The main issue was whether the defendant was entitled to modify the judgment under CPLR 5015(a). The holding of the case was that the defendant's motion to modify the judgment was properly denied by the Supreme Court. The defendant failed to specify on which grounds its motion was based, and it did not establish its entitlement to relief on any of the enumerated grounds. Furthermore, the court found that modification of the judgment in the interest of justice was not warranted.

The court considered the fact that the defendant had timely mailed its request and follow-up request for verification to the plaintiff, in accordance with the defendant's standard office practices and procedures. The plaintiff's medical biller had denied receipt of the verification requests, but the court found that this did not overcome the presumption that proper mailing had occurred. Since the plaintiff did not serve responses to the verification requests prior to the commencement of the action, the defendant's motion for summary judgment dismissing the complaint was properly granted. The main issue decided was whether the plaintiff's action for recovery of assigned first-party no-fault benefits was premature due to failure to provide requested verification of the claim. The holding of the court was that the judgment granting the defendant's motion for summary judgment was affirmed.

The parties in this case were the Unitrin Advantage Insurance Company and Bayshore Physical Therapy, PLLC. The court decided whether the insurance company could retroactively deny no-fault insurance claims on the basis of the assignors' failure to appear for independent medical examinations (IMEs). The court ruled that the insurance company can retroactively deny claims for failure to appear for IMEs, even if the initial denials were based on lack of medical necessity. Additionally, it was decided that a denial based on the breach of a condition precedent to coverage voids the policy from the beginning. The court also addressed that insurers can request IMEs in accordance with the procedures and timeframes set forth in the no-fault implementing regulations and if the assignors did not appear, the denial of claims is valid. Finally, the court found that the argument that all IMEs must be conducted by physicians was unavailing.