No-Fault Case Law

The court considered the appeal of a provider to recover first-party no-fault benefits. Plaintiff moved for summary judgment, but the motion was denied because the affidavit of plaintiff's corporate officer failed to establish personal knowledge of plaintiff's practices and procedures. Defendant argued that the affidavit did not lay a proper foundation for the documents annexed to plaintiff's moving papers, thus failing to establish a prima facie case. The court affirmed the order denying plaintiff's motion for summary judgment, stating that the affidavit submitted was insufficient to establish the officer's personal knowledge and therefore plaintiff failed to make a prima facie showing of entitlement to summary judgment. Therefore, the holding of the case was the denial of plaintiff's motion for summary judgment was properly affirmed.

The court considered the fact that the defendant insurer had admitted receiving the no-fault claims and had made partial payment on the claims. The main issue decided was whether the plaintiff had submitted proof that the claims had been mailed and received, and that they were overdue. The holding of the case was that the defendant insurer was not allowed to argue that the plaintiff had failed to submit the required proof, and that judgment was properly entered in favor of the plaintiff. The court also decided that the defendant waived any objections based on lack of proof of assignment since it did not seek verification of the assignment.

The provider's assignor received services on July 31, 2003, and MVAIC received the proof of claim in March 2004. The provider had earlier submitted the claim to another insurer whose policy had been cancelled, and MVAIC denied the claim as untimely while inviting a reasonable justification for the delay. The court held that MVAIC has the rights and obligations of an article 51 insurer, including the 45-day notice requirement. Even assuming the initial submission to the wrong insurer justified some delay, the provider gave no reasonable justification for the further delay of about three and a half months after learning there was no coverage. The order granting MVAIC summary judgment was affirmed.

The provider sued MVAIC for $1,080 in no-fault benefits arising from a July 2003 accident, and MVAIC moved for summary judgment because no notice of intention to make a claim was filed within 180 days under Insurance Law 5208(a)(1). MVAIC's claims examiner stated that no notice appeared in the file or its computer records. The provider's counsel did not deny that no notice was filed and argued that MVAIC had sent a letter denying qualification while time remained. The court held that MVAIC's lack-of-coverage defense was not waived by its failure to deny the bills. The provider offered no proof of reliance supporting equitable estoppel, so MVAIC's motion was granted and the complaint dismissed.

The relevant facts considered by the court in Umed Med., P.C. v State Farm Ins. Co. included an action by a provider to recover first-party no-fault benefits, and whether the insurer raised a triable issue of fact by proffering sufficient evidence to demonstrate a founded belief that the injuries did not arise out of an insured incident, but were staged. The main issue decided was whether the insurer's submission of a sworn affidavit of its special investigator was sufficient to demonstrate a founded belief, despite containing hearsay allegations. The holding of the case was that the branch of the plaintiff's motion seeking summary judgment on its third cause of action should have been denied, as the insurer's evidence was deemed insufficient to require a trial on material issues.

The court considered the fact that the plaintiff, IVB Medical Supply, Inc., sought to recover first-party no-fault benefits following an accident. The defendant, State Farm Mutual Insurance Co., argued that the insurance policy had been canceled prior to the accident. The main issue decided was whether the plaintiff was entitled to summary judgment, and whether the insurance policy had been validly canceled. The court held that the plaintiff failed to make a prima facie showing of entitlement to summary judgment, as the affidavit submitted did not prove the officer's personal knowledge of the company's practices. Additionally, the court found that the defendant did not meet its burden in proving the cancellation of the insurance policy, as it did not provide evidence that the cancellation notice was mailed. As a result, the court affirmed the denial of the plaintiff's motion for summary judgment and the rejection of the defendant's cross motion for summary judgment.

The relevant facts considered by the court in this case include the plaintiff's motion for summary judgment to recover assigned first-party no-fault benefits, which was supported by an affirmation of the plaintiff's counsel, an affidavit by a corporate officer of the plaintiff, and various documents attached to the motion papers. The defendant argued that the affidavit by the plaintiff's corporate officer failed to demonstrate personal knowledge of the facts set forth therein, and as a result, plaintiff failed to establish a prima facie case. The main issue decided by the court was whether the affidavit submitted by the plaintiff's corporate officer was sufficient to establish that the officer possessed personal knowledge of the plaintiff's practices and procedures to lay a foundation for the admissibility of the documents as business records. The court held that the affidavit was insufficient to establish personal knowledge, and therefore, plaintiff failed to make a prima facie showing of its entitlement to summary judgment. As a result, the motion for summary judgment was properly denied. Ultimately, the holding of the case was that the plaintiff failed to establish a prima facie case for summary judgment, and the denial of the motion for summary judgment was affirmed by the court.

The court considered the case of Forrest Chen Acupuncture Services, P.C. v. GEICO Insurance Co. in which the provider sought to recover assigned first-party no-fault benefits for acupuncture treatments provided in 2001. GEICO Insurance Co had paid the claims at a reduced rate, citing the absence of a fee schedule for such treatments and authorizing benefits at a "reasonable and customary fee for physical therapy." Plaintiff argued that this reduction was not authorized, but the court ruled in favor of the defendant, stating that the Superintendent of Insurance's interpretation of the regulations will be upheld in deference to his special competence and expertise with respect to the insurance industry unless it runs counter to the clear wording of a statutory provision. The court affirmed the denial of the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment based on Insurance Law § 5108 (b), which allows the insurer to determine that unusual procedures or unique circumstances justify an excess charge. The decision was made on April 26, 2007.

The provider moved for summary judgment for assigned no-fault benefits, and the insurer cross-moved to dismiss, relying on the assignor's failure to attend independent medical examinations. The insurer was required to prove the nonappearance by admissible evidence, but the Appellate Term held that it did not do so. The insurer therefore failed to raise a triable issue and its cross motion also failed. The order was reversed, the provider's motion was granted, and the matter was remanded for calculation of interest and attorney's fees. One judge dissented in part, concluding that the insurer's affidavits raised an issue of fact.

The court reversed the original judgment without costs and vacated the order entered on December 16, 2005. I & B Surgical Supply, an assignee of Jean Elie, commenced an action to recover $3,024.05 in first-party no-fault benefits for medical supplies. Defendant, New York Central Mutual Fire Ins. Co., moved for summary judgment to dismiss the plaintiff's claims for $1,280.30 and $1,017. The defendant's passive case established that the denial of these claims was timely and that the plaintiff did not establish the existence of a triable issue of fact. However, regarding another claim for $726.75, the defendant did not prove that its time to pay or deny the claim was tolled. The court held that the lower court improvidently considered and granted the plaintiff's cross motion for summary judgment and that plaintiff did not establish a triable issue of fact as to the aforementioned claims. Therefore, the motion for summary judgment was granted to the extent of awarding partial summary judgment dismissing plaintiff's claims for the sums of $1,280.30 and $1,017, and the matter was remanded for all further proceedings.