No-Fault Case Law

The main issues considered in this case were whether Geico, the petitioner, was aware of the respondents' uninsured motorist claim in June 2003 and whether they failed to request discovery for 10 months, as well as whether the notice of intention to make a claim for UM benefits constituted notice of the UM claim. The court considered the fact that the respondents had served a notice of intention to make a claim for UM benefits in June 2003 and Geico did not request discovery until after they demanded arbitration. The court held that, based on the facts presented, the petitioner failed to timely request discovery and denied Geico's petition to permanently or temporarily stay the UM arbitration demanded by the respondents pending their provision of such discovery. The court affirmed its original determination and adhered to it upon reargument.

A hospital sued the New York City Transit Authority, a self-insurer, for no-fault medical payments. The hospital showed that the Authority did not respond to its November 20, 2003 claim within 30 days as required by 11 NYCRR 65-3.8(c), and Supreme Court denied the hospital's motion and granted the Authority's cross motion to dismiss. The Appellate Division found the Authority's evidence insufficient to establish its own entitlement to judgment but sufficient to raise a triable issue of fact as to whether the claim was timely denied. The order was modified to deny the cross motion and otherwise affirmed.

A hospital assignee obtained a default judgment in an action for no-fault medical payments, and the insurer moved to vacate it and for leave to serve a late answer under CPLR 317 and 5015(a)(1). The Appellate Division held that under either provision the insurer had to show a meritorious defense, but it submitted no proposed answer and no affidavit from a person with personal knowledge. The insurer had neither paid nor denied the claims within 30 days and had not requested verification within the prescribed time, and its affidavit did not show that the injuries did not arise from an insured incident. It was therefore precluded from disclaiming coverage, and the order vacating the judgment was reversed and the judgment reinstated.

The main issue in this case was whether the defendant, State-Wide Insurance Co., was legally bound by an alleged settlement agreement reached with the plaintiff, Brooklyn Heights Medical, to pay first-party No-Fault benefits for healthcare services rendered to the plaintiff's assignor. The court considered the facts surrounding the negotiation and communication of the settlement agreement, including the exchange of unsigned documents, and whether the defendant's failure to sign and submit payment constituted rejection of the settlement offer. The court held that the defendant was not legally bound by the settlement agreement as neither the plaintiff nor plaintiff's counsel signed the stipulation at issue. The court also denied both the defendant's motion to vacate the judgment against it and enforce the settlement, as well as the plaintiff's cross-motion for sanctions and costs, finding that neither party acted in bad faith. Therefore, the motion and cross-motion were both denied.

The court considered the plaintiff's motion for summary judgment and the defendant's cross-motion to compel depositions of plaintiff, plaintiff's assignor, and plaintiff's treating physicians. The main issue decided was whether the plaintiff was entitled to first-party No-Fault benefits for healthcare services rendered to plaintiff's assignor following an accident. The court held that the plaintiff had submitted proof demonstrating its entitlement for the benefits, shifting the burden to the defendant. The court also held that the defendant's denials based on the assignor's failure to attend independent medical examinations were ineffective, and that the defendant's lack of coverage defense was not supported by sufficient evidence. Therefore, the plaintiff was awarded summary judgment in the amount of $2,299 plus statutory interest, costs, and attorneys' fees.

The main issue the court had to decide in this case was whether the plaintiff health care providers were entitled to summary judgment for first-party no-fault benefits for medical services rendered to their assignors for injuries sustained in a motor vehicle accident. The court found that with the exception of three out of 58 claims, the plaintiffs had established a prima facie entitlement to summary judgment by showing that they submitted claims setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The court also found that the defendant insurance company failed to pay or properly deny 55 of the claims within the prescribed 30-day period, precluding it from raising most defenses. The holding of the case was that the plaintiffs were entitled to partial summary judgment in the sum of $22,851.16 on the claims for which summary judgment was granted, and the matter was remanded to the court for a calculation of the statutory interest and an assessment of attorney's fees due on that sum, as well as for further proceedings on the remaining three claims.

The relevant facts the court considered in Contemp. Med. Diag. & Treatment, P.C. v Government Employees Ins. Co. were that plaintiff was seeking first-party no-fault benefits for medical services rendered to its assignors, and defendant had failed to pay or deny the claims within 30 days of receipt. Plaintiff alleged that defendant had also failed to extend the statutory time period by issuing a timely verification request on the prescribed forms. Plaintiff moved for summary judgment on these grounds, and defendant opposed the motion and cross-moved for summary judgment, claiming it had sent timely letter requests for verification which tolled the 30-day period within which it was obligated to pay or deny the claim. The main issue decided in this case was whether or not defendant's verification requests were made on the prescribed forms, and if they could be made by letter. The court disagreed with the lower court's determination that a request for additional verification may not be made by letter and must be made on a prescribed form, but they affirmed the order on constraint of a previous case, stating that the defendant failed to establish by competent evidence that it timely mailed its verification requests, and the 30-day period within which it was required to pay or deny the claim was therefore not tolled. As a result, the holding of the case was that the plaintiff was entitled to summary judgment, and the judgment of the lower court was affirmed without costs.

A supplier sued to recover first-party no-fault benefits for medical supplies provided to its assignor, and the Civil Court denied its motion for summary judgment. The Appellate Term found a prima facie case based on proof that claims were submitted and payment was overdue. The insurer opposed with a conclusory statement from someone without personal knowledge that it sent requests for independent medical examinations which the assignor failed to attend. Because the insurer did not describe any standard office practice to ensure the requests were properly addressed and mailed, it raised no triable issue. The order was reversed, summary judgment was granted, and the matter was remanded for interest and attorney's fees.

The court considered an appeal by plaintiffs, A.B. Medical Services PLLC and Royalton Chiropractic P.C., seeking to recover first-party no-fault benefits for medical services rendered to their assignors. A.B. Medical Services PLLC, in particular, sought the sum of $8,182.88. The main issue decided was whether A.B. Medical Services PLLC was entitled to the no-fault benefits as the billing provider, even though the medical services were rendered by an independent contractor, as indicated on the NF-3 claim forms. The holding of the court was that A.B. Medical Services PLLC was not entitled to recover "direct payment" of assigned no-fault benefits from the defendant insurer, as it was not the provider of the instant services within the meaning of the relevant section, despite being a licensed provider of health care services. Therefore, the complaint as to plaintiff A.B. Medical Services PLLC was dismissed.

In the legal case of Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co., the plaintiff sought to recover first-party no-fault benefits for medical treatment. Plaintiff established its prima facie case for summary judgment by proving the statutory billing forms had been received and that payment was overdue. Defendant was allowed to assert a defense that the collision was in furtherance of an insurance fraud scheme. The court found that the affidavit submitted by defendant's special investigator was sufficient to demonstrate that defendant's denial was based upon a well-founded belief that the alleged injuries did not arise out of an insured incident. Plaintiff's motion for summary judgment was properly denied as defendant demonstrated a triable issue of fact as to whether there was a lack of coverage. The court also found that defendant's opposition to plaintiff's motion for summary judgment based on the assignor’s failure to attend examinations under oath was without merit.