No-Fault Case Law

The main issue in Radiology Resource Network, P.C. v Fireman's Fund Insurance Company was whether the trial court erred in granting the defendant's motion to sever 68 assigned claims for no-fault insurance benefits into separate actions. The defendant argued that the claims arose from 68 different accidents, had been assigned to 68 different assignors, and raised unique legal and factual issues. The court decided that the trial court had not erred in granting the defendant's motion to sever the claims, as each claim raised unique legal and factual issues that would be better handled in separate actions. The court held that trying all 68 claims together would be unwieldy and would create a substantial risk of confusion for the trier of fact, and since the claims were likely to raise few common issues of law or fact, severing the claims was the best approach. The court drew upon a recent federal decision in a similar case, which stated that the assigned claims "arise out of distinct automobile accidents which led to different injuries to different individuals who underwent distinct medical services, payment for which was denied for varying reasons."

The court considered that plaintiff brought a suit to recover no-fault insurance coverage for medical services it provided to an individual who was insured with the defendant. Defendant moved for summary judgment, arguing that plaintiff's commencement of the action was premature due to plaintiff's failure to comply with defendant's verification requests. Plaintiff opposed defendant's motion, arguing that defendant's follow-up request was untimely. The court found that the defendant's verification requests were timely and proper according to the no-fault regulations. The court held that the plaintiff commenced the action prematurely as the defendant's verification requests were deemed timely and proper, and as the plaintiff did not respond to the timely and proper requests, the defendant was under no duty to issue a denial.

The main issue in the case was whether South Nassau Communities Hospital was entitled to recover unpaid benefits under the no-fault provisions of the Insurance Law. The court considered whether the hospital had made a prima facie showing of entitlement to summary judgment as a matter of law and whether there were any material issues of fact. The court ultimately denied the hospital's motion for summary judgment, finding that the hospital did not sustain its burden in demonstrating that the claims at issue were not subjects of previous billings that were resolved. Therefore, the court held that the hospital's papers failed to eliminate triable issues of fact, and it did not examine the adequacy of the defendant's papers in opposition to the motion.

The court considered the issue of whether petitioner State Farm Mutual Automobile Insurance Company submitted sufficient documentary proof to show that its no-fault payments to its subrogor were within the three year statute of limitations. The main issue decided was whether the arbitrator's dismissal of the claim as barred by the statute of limitations was arbitrary and capricious. The court held that State Farm did submit enough documentary proof to establish the dates of the initial payments and that the arbitrator's dismissal of the claim was not based on evidence. As a result, the court reversed the order denying State Farm's petition, granted the petition, vacated the arbitrator's award, and remanded the matter for arbitration.

The court considered the denial of first party benefits under New York's No-Fault Insurance Law for two assignors, Cadet and Gousse, who were injured in a motor vehicle accident. The main issue was whether the denials of benefits were received within the statutorily mandated 30 days after the receipt of the claims, as well as the sufficiency of the Examinations Under Oath (EUO) submitted by the defendant insurer. The holding of the court was that the denials were not received within the mandated 30 days, and the EUO submitted by the defendant insurer was not in a legally admissible form. Additionally, it was found that the insurer did not follow the procedures in seeking a second date for the EUO when Gousse failed to attend the first scheduled examination, therefore the 30-day statutory period was not tolled. The court granted the plaintiff's motion for summary judgment and awarded judgment in the amount of $4460 plus interest and attorney's fees.

The court considered the circumstances surrounding the denial of first-party benefits for an injury claim made by a medical provider to an insurance company. In this case, the injured party was in a car accident while driving the insured's vehicle, prompting the medical provider to submit claims for first-party benefits to the insurance company. The insurance company subsequently requested additional verification of the claims through an examination under oath (EUO) from the driver. However, the request was not received by the driver because the address used was incorrect. Additionally, the insurance company conducted EUOs with the passenger and the insured, then denied the claims for the passenger's treatments based on inconsistencies between the statements of the passenger and the insured. The main issues were whether the request for the EUO to the injured party's attorney was sufficient notification under New York's No-Fault Law and whether a denial of first-party benefits could be based on statements and suppositions made by someone lacking personal knowledge. The court held that the insurance company failed to make a legally valid request for verification within the prescribed time period and that the denial of benefits was untimely. Additionally, the court found that the denial of benefits based on unsubstantiated hypotheses and suppositions made by someone lacking personal knowledge was not sufficient, granting summary judgment for the plaintiff.

The court considered the insurer's obligation to provide a proper denial of claim uner New York regulations stating either to pay or deny a claim within 30 calendar days after proof of claim was received. The plaintiff submitted two claims to the insurer to recover no-fault medical payments but the defendant responded with a standard denial of claim which failed to include several important details. Including the name of the health services provider, the date and amount of the claims being denied, and the date it received those claims. The insurer contended it supplied the missing information after the 30-day period, however, the court found that the insurer's denial of claim was factually insufficient, conclusory, vague, and otherwise involves a defense that has no merit as a matter of law. The holding of the case was that the plaintiff's motion for summary judgment should have been granted on the ground that the April 14, 2003, denial of claim was fatally defective.

The court considered the submissions by both the plaintiff and defendant, including the affidavit of the defendant's special investigator supported by examinations under oath taken of the plaintiff's assignor and other persons involved in the accident. The main issue decided was whether the defendant's submissions raised a triable issue of fact as to whether the collision was part of a fraudulent insurance scheme. The holding of the court was that the defendant's submissions were sufficient to raise a triable issue of fact, and therefore the plaintiff's motion for summary judgment was properly denied.

The main issue in this case was whether the plaintiff, a healthcare provider, was entitled to summary judgment on its claim for first-party no-fault benefits for services rendered to its assignor. The plaintiff had submitted a complete proof of claim to the defendant, an insurance company, and the defendant failed to pay or deny the claim within the prescribed 30-day period. The court found that the defendant's requests for examinations under oath did not toll the 30-day period, as the insurance regulations in effect at the time did not require a claimant to appear for an examination under oath. The court held that the defendant was precluded from asserting most defenses due to the untimely denial of the claims, but was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme. The defendant's special investigator submitted an affidavit demonstrating a "founded belief that the alleged injuries do not arise out of an insured incident," and the court found that this was sufficient to demonstrate the existence of a triable issue of fact. Therefore, the plaintiff's motion for summary judgment was properly denied by the court. Ultimately, the holding of the case was that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, and as a result, the plaintiff's motion for summary judgment was properly denied.

The court considered the claim by S & M Supply Inc. to recover first-party no-fault benefits for medical equipment provided to its assignors. S & M Supply Inc. established its entitlement to summary judgment by submitting properly executed claim forms. The main issue decided was that the defendant, State Farm Mutual Automobile Insurance Company, failed to pay or deny the claims within 30 days of receipt, which precluded its defense based on the assignors' failures to attend examinations under oath. However, the preclusion rule was found to be inapplicable to a claim that the underlying traffic incident was deliberate and staged as part of a scheme to defraud, which would constitute a complete defense to the action. The holding of the case was that the defendant's submissions sufficed to demonstrate a "founded belief that the alleged injury did not arise out of an insured incident," which supported their defense.