No-Fault Case Law
Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co. (2005 NY Slip Op 02235)
March 21, 2005
The court considered the action to recover no-fault insurance medical payments. Nyack Hospital, as Assignee of John Watson, was the respondent and Metropolitan Property & Casualty Insurance Company was the appellant. The court granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment dismissing the complaint. The plaintiff provided evidence that the prescribed statutory billing forms were mailed and received, and that payment of no-fault benefits was overdue. The defendant failed to raise a triable issue of fact in opposition. The court affirmed the order, with costs, based on the plaintiff's prima facie showing of entitlement to judgment as a matter of law.
Simmons v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 02105)
March 18, 2005
The case involved a dispute between Patricia Simmons and State Farm Mutual Automobile Insurance Company. After State Farm refused to continue providing no-fault insurance benefits to Patricia Simmons, she and other plaintiffs commenced legal action against the insurance company. The main issue was whether State Farm had met its burden of showing lack of cooperation of its insured and had established that the plaintiff was able to return to work. The court decided that State Farm failed to meet its burden of showing lack of cooperation of its insured and was unable to establish that the plaintiff was able to return to work. Therefore, the court affirmed the lower court's decision to grant State Farm's motion only in part and denied it with respect to the first cause of action, ultimately dismissing the complaint.
Socrates Psychological Servs., P.C. v Progressive Cas. Ins. Co. (2005 NY Slip Op 25096)
March 15, 2005
The court considered a dispute between a health care provider and an insurance company over the refusal of the insurance company to pay for services rendered to a patient. The key issue in this case was the proper scope of an examination before trial (EBT) in an action by a health care provider for no-fault first-party benefits. The court had to decide whether the questioning at an EBT should be confined to the insurer's denial of claim form, the NF-10, or whether other matters should be allowed. The court also noted that the defendant's attorney had served the court with a motion four months late, without excuse or justification. The court held that the briefing schedules should be adhered to, and judges should scrupulously enforce deadlines set by fellow judges. Furthermore, the court would not consider papers that were untimely under a schedule.
Matter of Eagle Ins. Co. v Hamilton (2005 NY Slip Op 01906)
March 14, 2005
The court considered whether an insurer was required to provide uninsured motorist coverage in a claim involving an accident and whether or not the policy holder had options to pursue coverage from another source. The main issue was whether the alleged tortfeasor's insurer, who was now insolvent, triggered the harmful uninsured motorist coverage. The court held that under these circumstances, the coverage was not provided, and that the insured party's recourse was against the Public Motor Vehicle Liability Security Fund rather than his own insurer. They also discussed whether a request for recovery from the Fund would result in a denial of coverage from the Fund, thereby triggering the insured party's right to coverage from his own provider. It was determined that the matter should be remitted back to the Supreme Court for further proceedings.
Green v Liberty Mut. Ins. Co. Trust (2005 NY Slip Op 01869)
March 14, 2005
The court considered the appellant's claim that he was entitled to a de novo trial of his no-fault claim based on the amount in controversy, as the master arbitrator made no monetary award, and the statutory predicate for a de novo court adjudication was not satisfied. The main issue decided by the court was whether the appellant was entitled to a de novo trial under Insurance Law § 5106 (c) as the master arbitrator's award was $5,000 or greater. The court decided that the appellant was not entitled to a de novo trial because the master arbitrator made no monetary award and thus the statutory predicate for a de novo court adjudication was not satisfied. The holding of the case was that the appellant was not constitutionally entitled to a de novo trial, as the Insurance Law § 5106(c) does not violate due process and equal protection because the classification it creates between claimants and insurance carriers is reasonably related to a legitimate state interest and has a rational basis.
Vista Surgical Supplies, Inc. v Utica Mut. Ins. Co. (2005 NY Slip Op 25091)
March 10, 2005
The court considered the plaintiff's motion for summary judgment pursuant to CPLR 3212, where Vista Surgical Supplies, Inc. sought to recover first-party no-fault benefits in the amount of $1,282 for medical supplies furnished to the plaintiff's assignor. Plaintiff's argument was that the defendant had failed to timely deny its no-fault claims. The court held that in a no-fault context, a health care provider must establish prima facie entitlement to summary judgment as a matter of law by submitting admissible proof that it is an assignee under a properly executed assignment, that the statutory claim form was mailed to and received by the defendant, and that payment of no-fault benefits is overdue. However, the court found that plaintiff's evidence was insufficient, as the affidavit submitted by plaintiff's officer contained boilerplate language and did not provide specific material facts. Therefore, the plaintiff's motion for summary judgment was denied.
A.B. Med. Servs., PLLC v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25089)
March 9, 2005
The main issue in the case was whether the alleged injuries in automobile collisions arose from "staged accidents" and the subsequent impact on coverage for first-party no-fault benefits. The court considered the insurer's "founded belief" that the collisions were "staged" and whether State Farm had provided enough evidence to establish this belief. The court held in favor of State Farm, dismissing the claims and finding that the State Farm policies did not provide coverage for the claims at issue. The court considered the burden of proof in establishing coverage under the policy, the evidence submitted by the insurer, and the failure of the plaintiffs to rebut the insurer's belief. The court also discussed the inadmissibility of certain information used by State Farm and highlighted the repercussions for the providers and the assignor if the insurer does not pay due to lack of coverage.
Matter of Government Empls. Ins. Co. v Batista (2005 NY Slip Op 50926(U))
March 7, 2005
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.
Hospital for Joint Diseases v New York City Tr. Auth. (2005 NY Slip Op 01679)
March 7, 2005
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.
New York Hosp. Med. Ctr. of Queens v Insurance Co. of State of Pa. (2005 NY Slip Op 01691)
March 7, 2005
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.