No-Fault Case Law

The case involved a dispute over an action to recover no-fault medical payments under insurance contracts. The plaintiffs appealed the lower court’s denial of their summary judgment motion, while the defendant cross-appealed from portions of the order denying their cross motion for summary judgment dismissing the complaint. The court held that the defendant was not obligated to pay or deny the claim until receiving verification of all relevant information requested. The defendant was found to be entitled to summary judgment dismissing both the first and second causes of action, as the plaintiffs failed to respond to the defendant’s request for verification. The defendant’s cross motion was granted, along with an award of costs, and the plaintiff’s complaint was dismissed. The denial of the defendant’s summary judgment motion was reversed, and the plaintiff’s second cause of action was dismissed as well, given the lack of a timely response to the defendant’s request for verification.

A provider, as assignee, sued the Motor Vehicle Accident Indemnification Corporation for no-fault benefits for services rendered between 1998 and 1999, and the suit was commenced in September 2004. MVAIC moved to dismiss as time-barred. The plaintiff argued for the six-year contract limitations period of CPLR 213. The court reviewed Court of Appeals and Appellate Division authority and reasoned that MVAIC's obligation to pay no-fault benefits is purely statutory. It held that the three-year limitations period of CPLR 214 applies to actions against MVAIC, granted the motion to dismiss, and deemed the plaintiff's summary judgment motion moot.

The court considered a case in which the plaintiffs appealed an order that granted the defendants' motion to dismiss their complaint, which declared that a specific regulation violated procedural due process and was unconstitutional. The plaintiffs argued that the regulation allowed for an arbitrator to raise any issues relevant to making an award without giving them a meaningful opportunity to respond, and that it was unconstitutional as applied to them. The court held that the regulation did not violate procedural due process and that there is a strong government interest in according the arbitrator discretion in order to promptly resolve claims. The court also ruled that while the challenge regulation comported with procedural due process, the Supreme Court should have made a declaration as to the constitutionality of the regulation. Therefore, the matter was remitted to the Supreme Court, Kings County, for entry of a judgment declaring that the regulation does not violate procedural due process.

The pertinent facts in the present case involve a plaintiff seeking to recover overdue no-fault payments for services provided to an assignor. The defendant filed for summary judgment to dismiss the action, claiming the plaintiff was fraudulently organized and therefore not entitled to recover on the no-fault benefits claim. The main issue decided by the court was whether the fraudulently licensed corporation was entitled to reimbursement under New York Insurance Law for medical services provided by licensed medical practitioners, and if 11 NYCRR 65-3.16 (a) (12) applies to unpaid claims that accrued prior to April 4, 2002. The court denied the defendant's motion for summary judgment, stating that the regulation is not retroactively applicable to any claim for treatment provided prior to April 4, 2002, and the other defenses raised by the defendant's motion papers were unavailable, as the defendant failed to show that these defenses were properly preserved in a timely denial of the claim. Moreover, the defendant's motion papers lacked a complete copy of the pleadings, as required by CPLR 3212 (b).

The court considered a case where the claimant sought supplemental underinsured motorist (SUM) benefits from Transcontinental Insurance Company (CNA) after being injured as a passenger in a van insured by CNA. The claimant fractured her femur in an accident involving the van, and CNA argued that the injury was not caused by the accident but rather by a subsequent fall on ice. The main issue was whether the claimant's injury was proximately caused by the insured vehicle, which would determine her eligibility for SUM benefits. The court held that the claimant's injuries were indeed proximately caused by the collision involving the van, and therefore she was entitled to proceed to arbitration for her SUM claim. The court found that CNA had not met its burden of proving that the injury was not caused by the insured vehicle, and directed the parties to proceed to arbitration.

A medical provider, as assignee, sued to recover $1,754.17 in no-fault benefits and moved for summary judgment, arguing that the insurer's denial form was fatally defective because large portions were left blank. The insurer had denied the claim for failure to cooperate with its investigation, and it served its opposition papers late. The court found the denial clearly defective because it omitted much of the information required on the prescribed form, so the insurer was precluded from offering evidence in opposition. It also found that the insurer received the verification responses on March 28, 2002, so the July 15, 2002 denial was untimely. The motion was granted and judgment was entered for the plaintiff for the principal amount plus statutory interest, attorney fees and costs.

The court considered the prima facie evidence submitted by A.B. Medical Services PLLC to establish their entitlement to partial summary judgment. The main issue decided was whether the insurance company, Liberty Mutual, had provided timely payment or denial of claims. The holding of the court was to reverse the order denying partial summary judgment and to grant the motion by A.B. Medical Services PLLC for partial summary judgment in the sum of $4,410.22. The matter was also remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees due thereon pursuant to Insurance Law § 5106(a) and the regulations promulgated thereunder, and for further proceedings on its remaining claims. The appeal by plaintiffs Lvov Acupuncture P.C. and Somun Acupuncture P.C. was unanimously dismissed. The court also noted discrepancies in the NF-10 "Denial of Claim" form submitted by both parties, and one judge dissented, stating that the case should be remanded for further investigation due to the disturbing discrepancies found.

Nyack Hospital appealed an order denying its motion for summary judgment on its claim for statutory interest and an attorney's fee, and granting the defendant, Encompass Insurance Company, summary judgment dismissing the complaint. Nyack Hospital had made evidentiary proof that the prescribed billing forms were mailed and received and that payment of no-fault benefits was overdue when made. Encompass Insurance Company waived any defense based on the lack of a valid assignment, and letters from the company stating that payment was delayed pending investigation did not toll the 30-day statutory period for paying or denying the claim. The court held that the hospital was entitled to summary judgment on its claim for statutory interest and an attorney's fee, reversing the order of the lower court and remitting the matter to calculate the amount due to the hospital.

A supplier, as assignee, sued to recover first-party no-fault benefits for medical supplies and moved for summary judgment, which the Civil Court denied. The Appellate Term found that the plaintiff made a prima facie showing by proving that it submitted claims and that payment was overdue. In opposition, the defendant submitted documentation that the assignor's injuries were not caused by the accident. The court held that this established a founded belief that the injuries did not arise out of an insured incident, a defense not precluded by a late denial. The order denying summary judgment was affirmed.

The relevant facts the court considered in this case were related to a dispute over first party no-fault benefits for medical services rendered to patients of the plaintiff health care providers. The main issue was whether the plaintiff providers were entitled to summary judgment for unpaid claims, and whether the insurance company could require the patients to submit to examinations under oath. The court held that the plaintiff providers were entitled to summary judgment in the amount demanded in the complaint, as they had submitted claims and payment was overdue. The court also held that the insurance company could not require the patients to submit to examinations under oath, as the insurance policy did not contain the necessary endorsement authorizing such examinations. Therefore, the insurance company could not rely on revised regulations to argue that the plaintiffs had vitiated coverage by failing to comply with a condition precedent, and the decision was in favor of the plaintiffs.