No-Fault Case Law

The court considered the case of Star Medical Services, P.C. v Allstate Insurance Company, pertaining to the recovery of first-party no-fault benefits for medical services that were rendered. The main issue was whether the plaintiff health care provider had established a prima facie entitlement to summary judgment through proof of submitting claims and the overdue payment of no-fault benefits. The decision held that plaintiff was entitled to summary judgment in the principal sum of $1,791 with respect to the claims submitted on behalf of Naika Gousse. The matter was remanded to the court for calculation of statutory interest and attorney's fees due on those claims, as well as for all further proceedings on the remaining claims submitted on behalf of Jimmy Cadet. Additionally, the court concluded that the defendant failed to follow the requisite follow-up verification procedures and that claim denials based upon nonattendance for examinations under oath were ineffective. Finally, it was determined that the defendant's submissions were legally sufficient to support the allegations that the injuries did not arise out of an insured incident for the claims submitted on behalf of Jimmy Cadet.

The court considered a motion to vacate a default judgment entered against Allstate Insurance Company in an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignor. The main issues decided were whether the defendant established a reasonable excuse for the default and a meritorious defense to the action. The court held that the lower court had improvidently exercised its discretion in granting defendant's motion to vacate the default judgment. It was determined that the defendant did not show a reasonable excuse for the default and failed to sufficiently establish a meritorious defense. The court found that the defendant's moving papers did not include an affidavit by someone with personal knowledge of the underlying circumstances, and therefore did not meet the necessary burden of proof.

The case of East Coast Medical Care, P.C. v State Farm Mutual Auto. Ins. Co. involved a first-party claim for benefits under New York's No-Fault Insurance Law. After evidence was heard in the case, the presiding judge was unexpectedly reassigned from civil to criminal court, making it impossible to continue the trial. Neither party moved for a mistrial, and the determination that a mistrial was necessary was made by the court. The main issue was whether a court can declare a mistrial sua sponte over a party's objections when it becomes impossible for the trial judge to continue hearing the case. The court held that the decision as to whether or not to grant a new trial lies in the discretion of the court when a trial cannot proceed without injustice to a party, and in this case, the interests of justice required the declaration of a mistrial because evidence had been heard, no other judge could be substituted, and an indefinite continuance would be impracticable.

A provider, as assignee, sued the insurer for first-party no-fault benefits and moved for summary judgment on the ground that the insurer did not timely pay or deny. The insurer did not dispute that it missed the 30-day period or that it made no verification demand. It argued the plaintiff failed to make a prima facie case because the assignment of benefits form was defective in lacking an assignee, the accident date and an execution date. Following Appellate Term authority, the court held it is the insurer's burden to show an invalid assignment and that failure to object to the claim form within 10 days waived such technical defects. The plaintiff's motion was granted.

The relevant facts in this case were that Vista Surgical Supplies, Inc. was seeking to recover first-party no-fault benefits for medical supplies provided to its assignor. The main issue was whether Vista Surgical Supplies, Inc. had submitted its claim form to Allstate Insurance Co. The court held that Vista Surgical Supplies, Inc. did not establish its prima facie entitlement to summary judgment because it failed to conclusively show that it submitted its claim form to Allstate Insurance Co. The court also held that the provision of the order awarding defendant $250 in costs should be deleted. The decision was that Vista Surgical Supplies, Inc.'s motion for summary judgment was properly denied, and Allstate Insurance Co.'s cross motion for summary judgment should be denied, thus affirming the order without costs.

An acupuncture provider, as assignee, sued for first-party no-fault benefits and was granted summary judgment. The Appellate Term held that the insurer's first denial was facially insufficient because it omitted most of the required information. It also failed to set out the factual basis and medical rationale for a lack-of-medical-necessity defense based on an independent medical examination report. The second denial was untimely, precluding the defenses, and verification demands made before the claims were received did not toll the 30-day period. The order granting the plaintiff summary judgment was affirmed.

A provider, as assignee, sued for no-fault benefits for medical supplies and moved for summary judgment, claiming the insurer did not timely pay or deny. The insurer cross-moved on the ground of lack of medical necessity, a defense that is waived if not in a timely denial. The court found the plaintiff made a prima facie case. The insurer's claims representative's affidavit described office mailing practices and raised a triable issue as to whether the denial was timely mailed, but lacking personal knowledge of actual mailing it did not entitle the insurer to judgment. Both motions were denied.

The court considered the fact that the plaintiff had submitted a statutory claim form for first-party no-fault benefits for medical services provided to the injured assignor. The main issue decided was whether the defendant had established that verification requests were timely mailed. The court held that the defendant failed to prove the timely mailing of the verification requests and did not create a presumption of mailing by providing evidence of the standard operating procedures used to ensure that the verification requests were mailed. As a result, the court affirmed the order granting the plaintiff's motion for summary judgment and denying the defendant's cross motion.

The court considered the fact that Ocean Diagnostic Imaging had submitted claims for first-party no-fault benefits for medical services rendered to its assignors for injuries sustained in accidents in February and May 2003. The main issue decided was whether Ocean Diagnostic Imaging had established its entitlement to summary judgment by submitting claims and whether the insurance company had waived any defenses by failing to seek verification of the assignments. The holding of the case was that Ocean Diagnostic Imaging had established its entitlement to summary judgment and that the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees. The court also emphasized the principle that once a party affirmatively establishes an issue of fact, the other side must oppose it either factually or on legal grounds, or else that issue will be determined in favor of the proponent.

The relevant facts the court considered in this case were that Allstate Insurance Company sought to confirm an arbitration award in the principal sum of $17,348.79 against Republic Western Insurance Company, in a subrogation claim arising from an accident involving a U-Haul vehicle. The main issue decided was whether Republic Western had waived its right to contest the arbitrability of the claim by failing to apply for a stay of arbitration prior to arbitration. The holding of the case was that Republic Western had indeed waived its right to challenge the arbitrability of the claim, as it did not apply for a stay of arbitration prior to arbitration and did not conclusively establish that the U-Haul vehicle involved in the accident did not meet the weight requirements necessary to trigger the no-fault benefits authorized by the statute.