No-Fault Case Law

A hospital that had won summary judgment in its no-fault action obtained a judgment of $52,841.88 against two insurers, which then moved to reduce it below the $50,000 statutory limit and to quash an information subpoena. The evidence showed that payments to other providers and the hospital's initial claim totaled $23,744.21 and that the insurers paid the remaining $26,255.79, exhausting the policy limit. The Appellate Division held that once an insurer pays the full policy limits its duties under the contract cease. It rejected the argument that collateral estoppel barred the insurers from raising exhaustion and affirmed the order modifying the judgment and quashing the subpoena.

The relevant facts considered by the court involved a health care provider seeking to recover no-fault benefits, and the insurance company's failure to deny the claim within the statutory 30-day period. The main issue decided was whether the insurance company's failure to deny the claim within the 30-day period precluded it from interposing defenses other than a claim that the incident was staged to defraud. The holding of the case was that the insurance company's failure to deny the claim within the 30-day period, as well as its untimely requests for examinations under oath, violated the statutory time frames and precluded it from interposing defenses aside from the fraud claim. The court also concluded that the insurance company's proof of fraud was not submitted in admissible form, failing to raise a triable issue of fraud. The court affirmed the order without costs.

The court considered the plaintiff's motion for partial summary judgment in a case where D.A.V. Chiropractic P.C. sought first-party no-fault benefits for medical supplies furnished to its assignor. The main issue was whether the plaintiff had established a prima facie entitlement to summary judgment and whether the defendant's denial of claim forms, with unaffirmed peer reviews attached, raised a triable issue of fact regarding medical necessity. The court held that while the plaintiff had established a prima facie entitlement to summary judgment, the defendant's reliance on unaffirmed peer reviews which contained a sufficient factual basis and medical rationale raised a triable issue of fact regarding medical necessity, warranting the denial of the plaintiff's motion for partial summary judgment. The appeal made by plaintiff Daniel Kim's Acupuncture P.C. was dismissed.

The main issues were whether defendant established a tolling of the statutory time and whether plaintiff health care provider established its prima facie entitlement to summary judgment by proof that it submitted a statutory claim form setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The court held that the district court was right to grant plaintiff's motion for summary judgment and deny defendant's cross motion for summary judgment or an order compelling discovery. Defendant's conceded failure to deny the claim on time precluded most defenses unless it established a tolling of the statutory time. Also, the verification requests by the defendant failed to toll the claim determination period. Lastly, the defense that the incident was staged to defraud did not survive the preclusion sanction as plaintiff's proof offered to establish the defense was inadmissible form.

The court considered the case of A.B. Medical Services PLLC et al. as assignee of Sahara Abbott, who were appealing against Utica Mutual Insurance Company. The claimants were seeking partial summary judgment in the sums of $6,765.47 and $1,690.56 respectively. The main issues decided by the court were whether the defendant violated the 30-day claim determination period and precluded itself from interposing most defenses as to all claims mailed on or before November 2, 2002, and whether they demonstrated a tolling via proof that one or more of the notice of physical examination letters were issued and the plaintiffs failed to appear. The holding of the court includes the modification of the order by granting the plaintiffs' partial summary judgment in the declared sums and remanding other claims to the court below for a calculation of statutory interest and an assessment of attorney's fees. The appeal as taken by plaintiff Square Synagogue Transportation Inc. was unanimously dismissed. The court determined that the defendant failed to establish a triable issue of fraud and proper verification requests with respect to its letters, and that the letters issued were ineffective to toll the 30-day claim determination period.

The relevant facts considered by the court were that plaintiff, a healthcare provider, submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that defendant insurance company failed to pay or deny the claim within the prescribed period. The main issue decided was whether defendant was precluded from raising certain defenses due to the untimely denial of the claim, and whether the defense of insurance fraud scheme could be asserted. The holding of the case was that plaintiff was not entitled to summary judgment because defendant raised a triable issue of fact as to whether there was a lack of coverage, and the court erred in granting plaintiff's motion for summary judgment.

Providers sued as assignees for $6,417.02 in no-fault benefits and the insurer timely denied the claims based on the assignor's failure to attend scheduled and rescheduled IMEs. The insurer showed that the scheduling letters were mailed to the two addresses the assignor had provided. The Appellate Term held that attendance at an IME is a condition precedent to coverage under 11 NYCRR 65-1.1, so non-attendance bars an action for payment. It expressly declined to follow the contrary holding of the Second Department Appellate Term in Stephen Fogel Psychological. The plaintiffs raised no issue of fact on reasonableness of the request or the failure to attend. The court affirmed summary judgment for the insurer.

The court considered whether a statutory arbitration proceeding to resolve a coverage dispute concerning an uninsured motorist claim is a claim founded upon a tort requiring the service of a notice of claim as a condition precedent to the commencement of an action. The main issue decided was whether a self-insured municipality is required to provide mandatory uninsured motorist benefits to employees who operate municipal motor vehicles. The holding was that although the lower court erred in dismissing the petition for failure to comply with a particular law, the court never reached the issue, so the matter was remitted to the Supreme Court for a framed issue hearing to determine whether the municipality received notice given by or on behalf of the injured person as soon as was reasonably practicable. In light of that determination, the appellant's remaining argument was considered academic.

Two actions by providers for an MRI bill of $902.28 and transportation charges of $550 were tried together. The parties stipulated to proper proof of claim and to timely denials based on the assignors' failure to appear for preclaim IMEs. The insurer proved mailing of the scheduling letters through testimony on its contractor's standard office practice, and the assignors did not attend. The court held that the insurer bears the burden on non-attendance and the provider bears the burden of persuasion on medical necessity after nonattendance. The providers' MRI report lacked a medical opinion connecting the findings to the accident, and the transportation letter was conclusory. The court awarded judgment to the insurer in both actions.

A physician sued as assignee for no-fault benefits and the Civil Court denied his summary judgment motion with leave to renew. The Appellate Term held that the insurer's failure to object to the adequacy of the claim form within 10 days of receipt waived any defenses based on it, including technical deficiencies in the assignment of benefits. The insurer therefore failed to raise a triable issue in response to the provider's prima facie showing. The court reversed and granted summary judgment of $3,072.08, remanding for interest and attorney's fees under Insurance Law § 5106 (a).