No-Fault Case Law

The case involved a plaintiff seeking first-party no-fault benefits for medical services rendered to its assignors. The plaintiff moved for summary judgment on its claims, arguing that the defendant failed to pay or deny the claims within the statutory 30-day period required by the Insurance Law. The defendant opposed the motion, asserting that it issued timely denials and citing lack of medical necessity as the reason for denying the claims. The court found that the defendant's denials were not timely on their face and that the affidavits submitted by the defendant did not establish mailing of the denials. As a result, the court granted the plaintiff's motion for summary judgment, awarding the plaintiff the amount of $3,177.54, together with statutory interest and attorney's fees.

The Court considered the fact that the plaintiff, a health care provider, brought a lawsuit to recover for services rendered under no-fault coverage. During the trial, the defendant sought to introduce certified transcripts of examinations under oath (EUOs) of nonparty assignors. The primary issue was whether the defendant could introduce EUO transcripts as evidence in the trial. The Court held that the defendant was precluded from introducing the EUO testimony of the assignors as evidence against the plaintiff, either by operation of the "New York rule" or the provisions of CPLR 3117 governing the admissibility of nonparty depositions. The Court ruled that the statements made by an assignor in an EUO may be offered by a defendant against the provider/assignee to prove a lack of coverage defense, but such statements are hearsay and are inadmissible at trial unless used for impeachment purposes upon cross-examination.

The relevant facts the court considered were that Star Medical Services, P.C. was seeking to recover first-party no-fault benefits for medical services rendered to its assignors from Allstate Insurance Company. The main issues decided included whether or not the failure of one of plaintiff's assignors to appear for an examination under oath (EUO) precludes summary judgment, and whether the alleged injuries arose out of a covered accident. The holding of the court was that the order granting plaintiff's motion for summary judgment should be affirmed, and defendant is precluded from raising most defenses, but not from asserting the defense that the alleged injuries do not arise out of a covered accident. The court also disagreed that the transcripts of the EUO testimony provided by one of plaintiff's assignors and by defendant's insured were insufficient to demonstrate that the defendant's denial was based upon a "founded belief that the alleged injuries do not arise out of an insured incident."

The court considered that the plaintiff's submitted statutory claim forms for loss and the fact that the payment of no-fault benefits was overdue, establishing a prima facie entitlement to summary judgment. Defendants rebutted the plaintiffs' case with evidence of an arbitral award which denied benefits for one of the claimants. The court held that the award should be accorded res judicata effect and that the plaintiffs were precluded from litigating this claim again. Additionally, the plaintiffs submitted some claims to arbitration and then withdrew them with prejudice. The court held that plaintiffs are bound by their election to arbitrate their claims and are precluded from maintaining the litigation. Furthermore, the court held that the remaining bills, except for one, were not the subject of arbitration and defendant's denials were untimely, making the denials ineffective to avoid preclusion. The remaining claims were dismissed, and judgment was entered in favor of the plaintiff for some claims and defendant for the remainder.

The relevant facts of the case include that the defendant, State Farm Mutual Auto Ins. Co., moved to dismiss the plaintiffs' actions for first-party no-fault benefits based on a declaratory judgment entered in Supreme Court. The plaintiffs were assignees of individuals involved in an accident and sought to recover medical benefits. State Farm argued that the declaratory judgment should have preclusive effect on the plaintiffs' actions. The main issue decided by the court was whether the plaintiffs should be bound by the declaratory judgment through collateral estoppel. The holding of the court was that collateral estoppel did not apply, and the plaintiffs were not bound by the terms of the declaratory judgment, as the assignments were made prior to the commencement of the declaratory judgment action and there was no identity of issues between the two actions. Therefore, the defendant's motion to dismiss the plaintiffs' actions was denied.

The main issue in this case was whether the insurer was justified in denying a claim for no-fault benefits for medical services provided to the plaintiff's assignor based on lack of medical necessity. The court considered the fact that the insurer denied the claim on the ground of lack of medical necessity based on a peer review report that concluded there was no medical necessity due to the lack of sufficient information. The court held that the insurer's denial was deficient, as it failed to set forth an adequate factual basis and medical rationale. The court also held that the insurer was not obligated to seek further verification if the peer review report clearly indicated that the pertinent physician's reports and other documentation had been requested and provided for the purpose of conducting a peer review. Therefore, the court reversed the order denying summary judgment, granted plaintiff's motion for summary judgment, and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees.

Fair Price Medical Supply sued a rental car company and its parent for first-party no-fault benefits for medical supplies, and its summary judgment motion was denied. The Appellate Term held the plaintiff's proof of submission of its claims was deficient and was cured only as to one $835.45 claim by the defendants' delay letters and denial form. As to that claim, the investigation letters did not toll the 30-day period, so most defenses were precluded. The defendants' assertion of a fraudulent scheme in the happening of the accident survived preclusion, and their papers showed a founded belief that the injuries did not arise out of an insured incident. The denial of summary judgment was affirmed.

A supplier, as assignee, sued a rental car company and its parent to recover assigned first-party no-fault benefits. After the court denied the plaintiff's summary judgment motion and granted the defendants' cross motion to compel discovery, the plaintiff failed to respond to the notice to produce as ordered. The defendants moved under CPLR 3126, the plaintiff served a response that still objected to two demands, and it cross-moved for a protective order. The Appellate Term held that because the plaintiff did not appeal the earlier order, it was obligated to provide the discovery. It found the plaintiff's willful noncompliance wasted judicial resources and affirmed the order directing an amended response and denying the protective order.

The relevant facts considered by the court included the failure of the plaintiff to adequately establish that they submitted the claim forms to the defendant. The main issue decided was whether the plaintiff demonstrated an entitlement to summary judgment on the first cause of action regarding the assignor Robert Gevorkov. The court held that the plaintiff did not provide proof of proper mailing of the claim forms regarding assignor Robert Gevorkov, and therefore, the lower court's order granting the plaintiff's motion for summary judgment was reversed and denied.

Fair Price Medical Supply sued a rental car company and its parent for first-party no-fault benefits for medical supplies, and its summary judgment motion was denied. The Appellate Term held that the defendants' investigation letters were not proper verification requests and did not toll the 30-day period, so they were precluded from most defenses. However, defendants asserted a fraudulent scheme in the happening of the accident, a defense that survives preclusion. Their papers showed a founded belief that the injuries did not arise out of an insured incident, raising a triable issue on coverage. The order denying summary judgment was affirmed.