No-Fault Case Law

The court considered the fact that the petitioner, Georgia Taylor, sustained work-related injuries in 1990 and received workers' compensation benefits. In 1992, the respondent, Continental Insurance Company, notified Taylor that they reserved the right to a lien on any recovery she received from the accident, and Taylor would need written consent from Continental to settle any third-party lawsuit related to the accident. Taylor breached this obligation when she settled a third-party action in 1993 without obtaining Continental's consent. In 2002, Taylor sought judicial approval of the settlement nunc pro tunc, but Continental refused. The issue was whether the delay in Taylor's application was the result of her fault or neglect and whether the settlement was reasonable, and the court ultimately decided that the delay in applying for judicial approval was inordinate, and the Supreme Court's grant of Taylor's application constituted an improvident exercise of discretion. Therefore, the order was reversed, and Taylor's application was denied.

Two provider plaintiffs sued to recover first-party no-fault benefits, statutory interest and attorney's fees for services rendered to assignors injured in an automobile accident. The Civil Court denied their summary judgment motion without prejudice to renewal after discovery. The supporting affidavit came from a billing manager of 'plaintiff' even though there were two distinct plaintiffs, and it did not state for which one she acted. The Appellate Term held the affidavit insufficient to show that properly completed claim forms were provided to the insurer, so plaintiffs made no prima facie showing. The denial of the motion was affirmed on that ground.

The court considered an action to recover no-fault medical payments under insurance contracts, in which the defendant appealed from an order granting summary judgment on the causes of action to recover no-fault medical payments allegedly due to two hospitals. The main issue that was decided involved the timely submission of complete proof of claim for no-fault benefits, as required by Insurance Law § 5106 and 11 NYCRR 65.12. The court found that both of these plaintiffs demonstrated a showing of entitlement to judgment as evidence that their claims were neither denied nor paid within the required time period. However, in opposition, the defendant offered enough evidence to raise a factual issue, leading to the conclusion that summary judgment should not have been granted on those causes of action. Therefore, the parties' remaining contentions were either unnecessary to address or were without merit.

The court considered an appeal by the defendant insurance company from an order denying its motion for summary judgment in a case to recover first-party no-fault benefits. The main issue was whether the claim for benefits rendered on December 5, 2001 was submitted within 180 days as required by law. The court found that while the claim for benefits rendered on December 19, 2001 was timely submitted, the claim for benefits on December 5, 2001 was not received within 180 days, and the plaintiff failed to prove that it was mailed within the statutory time. Therefore, the court granted the defendant's motion for partial summary judgment, dismissing the claim as to $1,236.99 of the principal sum sought.

The main issues in this case were whether the plaintiff was entitled to recover first party benefits under No-Fault for transportation services provided to the plaintiff's assignor, and whether the defendant insurer's cross-motion for summary judgment should be entertained by the court. The court found that the plaintiff had failed to establish a prima facie case for entitlement to recover unpaid benefits under No-Fault, as the initial papers submitted were devoid of any assignment of benefits. The plaintiff's motion for summary judgment was denied, and the defendant's cross-motion for dismissal was also denied as premature due to a statutory stay. The court also ruled that the plaintiff's attempt to raise new issues in their cross-motion was improper and should not be entertained. The court found that the terms of the "so-ordered" stipulation between the parties were revived, with the only modification being an extension of time for the plaintiff to serve complete verified responses to the defendant's discovery demands.

The relevant facts the court considered were whether a denial of claim was untimely and if the insurer failed to pay or deny the claim within 30 days of its receipt in violation of Insurance Law. The main issue decided was whether the insurer's requests for comprehensive narrative and notices of examinations under oath were proper requests for verification, which would toll the 30-day period within which the insurer was obligated to pay or deny the claim. The holding of the court was that the denial was untimely because the verification requests were not in proper form and therefore were ineffective to toll the 30-day period. Additionally, the court found that the insurer's opposition papers did not establish an endorsement authorizing examinations under oath and failed to show by competent evidence that its verification requests were timely mailed, thus the insurer failed to establish a triable issue of fact. Furthermore, the court noted that a request for additional verification may be made by letter and need not be on a prescribed form.

The relevant facts in this case were that plaintiff was trying to recover assigned first-party no-fault benefits for medical services from defendant. Plaintiff submitted the claim forms in a timely manner, while defendant did not deny the claims until well beyond the 30-day statutory period. Defendant denied the claims on the basis that plaintiff's assignors failed to appear for scheduled examinations under oath and on the basis of alleged fraudulent conduct. Plaintiff established prima facie entitlement to summary judgment, defendant failed to raise any triable issues of fact, and the submissions in support of defendant's allegations of fraud did not constitute evidentiary proof in admissible form. The main issue decided was whether plaintiff was entitled to summary judgment, and the holding was that plaintiff's motion for summary judgment should have been granted, and the matter should be remanded for the calculation of statutory interest and an assessment of attorney's fees.

Four provider plaintiffs sued to recover first-party no-fault benefits for services to their assignor and moved for summary judgment. In support they submitted an affidavit from a person who described himself as the practice and billing manager of 'plaintiff,' although there were four distinct plaintiffs with differing addresses. The Appellate Term held the affidavit did not indicate for which plaintiff the affiant acted and so was insufficient to show that properly completed claim forms were provided to the insurer. The motion therefore failed for lack of a prima facie showing, and the order was affirmed. The court also noted that an insurer with a founded belief that an injury does not arise from an insured incident may assert a staged-accident or similar fraud defense.

The court considered whether a defendant has the cellular plans to deny treatment for medical payments under insurance contracts because of lack of proof of the assignments and whether the right for direct appeal must be dismissed if there is an already existing entry of judgment. The main issues decided were the appellant's failure to establish that they mailed the requests for verification of assignments in support of their claim and that the right to appeal had indeed terminated with the entry of judgment in the action. The holding of the court was that the Supreme Court had properly granted the plaintiffs' motion for summary judgment on the second, third, and fourth causes of action because the defendant failed to pay or deny each respective claim within the statutory 30-day period and did not establish proof of the assignments upon which the claims were based.

The relevant facts considered by the court in East Way Chiropractic, P.C. v Allstate Ins. Co. included the testimony of a billing department employee for the plaintiff, who verified patient files and billing records. The plaintiff brought an action against the defendant to recover no-fault payments under a uniform contract of insurance for four separate patients. The main issue decided in the case was whether the defendant timely denied the plaintiff's claims, as required by law. The court held that the defendant failed to establish that the denials were timely mailed within thirty days, as required by law, and as a result, judgment was awarded to the plaintiff for the amounts sought in the complaint for services provided to the four patients.