No-Fault Case Law

The petitioner insurer sought to stay arbitration of its insured's supplementary uninsured motorist claim, which arose after the other vehicle's insurer disclaimed coverage for failure to appear for an examination under oath. The petitioner challenged the disclaimer as not meeting the heavy burden for proving non-cooperation, but offered no factual proof against it. The court reasoned that under Regulation 35-D an uninsured vehicle includes one whose insurer denies coverage and that SUM is optional coverage that promises prompt recovery. It declined to require a judicial determination of the disclaimer's validity before arbitration, and refused pre-arbitration discovery. The petition to stay was denied.

The court considered a motion for summary judgment by the plaintiffs for statutory interest and attorneys' fees on no-fault claims that the defendant allegedly paid late. The main issue was whether the plaintiffs could "bundle" a series of de minimis actions that are related only by the defendant's common response to the claims underlying those actions. Additionally, the court considered whether it should grant summary judgment because the defendant had not opposed the motion and made no motion to sever. The court held that the action was based on a series of de minimis claims that may not be joined under CPLR 1002, and denied the motion for summary judgment, but gave the plaintiff leave to move to sever the plaintiffs and to renew the motion for summary judgment as to those plaintiffs.

Hospital assignees sued a rental car company for unpaid no-fault benefits, and the Supreme Court vacated a default judgment for two plaintiffs and dismissed the third cause of action. The Appellate Division held that the defendant showed a reasonable excuse for the default through law office failure, acted promptly and caused no prejudice. On the merits, the defendant received the claim form, timely demanded verification, which extended the 30-day period, and then made follow-up requests that went unanswered. It denied the claim more than 180 days after first notice, which was proper. The order was affirmed as reviewed and other appeals were dismissed.

The claimant was injured in a car crash and was denied no-fault benefits by her insurance company. This claimant was seeking supplementary uninsured motorist (SUM) benefits from their insurance company. After a lengthy series of doctor consultations, she eventually discovered she had severe injuries and pursued the SUM claim. The Supreme Court ruled in favor of the insurance company, determining the claimant did not provide timely notice of her claim. The appellate court disagreed, stating that the claimant acted with due diligence in ascertaining her claim, and the delay was reasonable. As a result, the court reversed the decision in favor of the insurance company, granting the application for a permanent stay of arbitration.

A medical supply provider sued for assigned first-party no-fault benefits and sought leave to enter a default judgment, while the insurer cross-moved to compel acceptance of a late answer. Jurisdiction was acquired by service on the Superintendent of Insurance, so the insurer had to show a reasonable excuse and a meritorious defense. The Appellate Term assumed a reasonable excuse but found no meritorious defense, as the insurer offered no admissible proof of a timely verification request and no affidavit from a person with personal knowledge to support a medical necessity defense. It reversed, granted the default judgment motion and denied the cross motion.

The court considered the plaintiff’s motion to strike the defendant’s seventh, eighth, and tenth affirmative defenses on the ground that they were not pleaded with the specificity required by CPLR 3016(b) in an action to recover first-party no-fault benefits under Insurance Law § 5101. The defendant State Farm Mutual Automobile Insurance Company denied a claim for first-party no-fault benefits in the amount of $757.00 for medical supplies provided to its assignor Edme Aenor in connection with injuries arising out of a September 2, 2002 motor vehicle accident. Defendant’s affirmative defenses asserted fraudulent conduct, fraudulently misrepresented costs, and that the medical supplies for which reimbursement is sought were not related to the accident. The court granted in part and denied in part plaintiff’s motion to strike, specifically striking defendant’s seventh and eighth affirmative defenses and that portion of defendant’s tenth affirmative defense alleging that "the medical supplies for which reimbursement is sought were never actually provided". The court held that these defenses were being stricken because of defendant’s admitted failure to pay or reject the claims within 30 days of receipt, but declined to strike the portion of defendant’s tenth affirmative defense alleging that "the medical supplies for which reimbursement is sought were not related to the accident."

The court considered a case where health care providers were seeking assigned no-fault benefits from an insurance company, State Farm Mutual Automobile Insurance Company. The main issue was whether the health care providers were entitled to summary judgment for assigned no-fault benefits, as well as whether the insurance company was precluded from asserting the defense of an insurance fraud scheme due to an untimely denial of the claims. The court held that the health care providers established their entitlement to summary judgment for assigned no-fault benefits, as the insurance company failed to pay or deny the claims within the prescribed 30-day period. However, the insurance company was not precluded from asserting the defense of an insurance fraud scheme, as the affidavit submitted by their special investigator demonstrated a "founded belief that the alleged injuries do not arise out of an insured incident." Therefore, the plaintiffs' motion for summary judgment was properly denied.

The main issue in this case was whether the plaintiff was entitled to summary judgment in its favor. The court considered the evidence presented by the plaintiff, which consisted of an affirmation of counsel, an unverified complaint, and an affidavit from "Ernest Horowitz MD," who stated that the assertions in his counsel's affirmation were true and correct. However, the court did not accept the attempted incorporation by reference of the factual allegations contained in the counsel's affirmation. The court also noted that the No-Fault Verification of Treatment furnished by the plaintiff's counsel to the court differed from what was apparently sent to the defendant upon submission of the claim. As a result, the court denied the plaintiff's motion seeking summary judgment and awarded costs to the defendant. The holding of the case was that the plaintiff's motion for summary judgment was denied, and costs were awarded to the defendant.

The main issue in this case was whether the award of an arbitrator denying the disputed billing for MRIs, based on lack of documented medical necessity, was arbitrary, capricious, or incorrect as a matter of law. The court considered the fact that the insurer failed to deny the claim within the prescribed thirty-day period, as well as the legal precedent regarding the burden of proof in first-party no-fault claims. The court held that the insurer is precluded from raising any defense other than lack of coverage when it fails to comply with the rule requiring it to deny a claim within thirty days. Therefore, the court vacated the decision of the Master Arbitrator and found for the petitioner in the amount of $1,791.73, with statutory interest and fees as established in section 5106(a) of the Insurance Law.

The court considered whether an insurer was required to pay out a claim for a first-party benefit pursuant to New York's No-Fault Insurance Law within the statutory 30-day period following submission of the claim. The insurer argued that it was not subject to the provisions of the law because the person allegedly injured in the motor vehicle accident did not submit to several requests for an examination under oath, and also that the accident was staged. The court found that Regulation 68-A applied to claims filed after its effective date, and therefore denied the plaintiff's motion for summary judgment. Additionally, the court found that the insurer's argument that the plaintiff's assignor was not a covered person because of alleged fraud was without merit due to a lack of evidence. Therefore, the plaintiff's motion for summary judgment was denied.