No-Fault Case Law
North Queens Surgical Ctr. v Lancer Ins. Co. (2025 NY Slip Op 50191(U))
February 13, 2025
The court considered several relevant facts, including that the plaintiff established a prima facie case for recovery of first-party no-fault benefits, and that the defendant had timely denied the claim based on a lack of medical necessity. It was also stipulated that the insurance policy limits were exhausted after the denial due to the defendant's subsequent payments on other claims. The main issue decided was whether the defendant could rely on the exhaustion of policy limits from subsequent payments to avoid liability for the claim denied. The court held that the defendant's argument was without merit, affirming the judgment in favor of the plaintiff and awarding the claimed amount.
Flatbush Acupuncture P.C. v Repwest Ins. Co. (2025 NY Slip Op 25032)
February 13, 2025
The court considered the facts surrounding a motor vehicle accident involving the assignor, Jose David Torres, who sustained injuries and for whom the plaintiff, Flatbush Acupuncture P.C., provided medical services and sought payment from Repwest Insurance Company. The key issues included whether the assignor's failure to appear for scheduled examinations under oath (EUOs) constituted a breach of a condition precedent for payment, and whether the insurer had a legitimate basis for requiring such examinations prior to making payment. The court ultimately decided that the insurer was justified in denying the claim due to the assignor's failure to attend the EUOs, which were deemed necessary under the relevant regulations. Consequently, the court granted the defendant's motion for summary judgment and denied the plaintiff's motion.
Allstate Ins. Co. v Kapeleris (2025 NY Slip Op 00839)
February 13, 2025
The court considered the facts surrounding a no-fault insurance claim, specifically focusing on Stacey Kapeleris's counterclaim against Allstate Insurance for benefits related to medical expenses. The main issues included whether the awarded amount of $25,109.88 for medical treatment was appropriate, as well as the reasonableness of the awarded attorneys' fees totaling $76,856.67. After a nonjury trial, the court found that Kapeleris incurred reasonable medical expenses and that her settlement with medical providers justified the amount claimed. Ultimately, the court affirmed the trial court's judgment in favor of the defendant, concluding that both the compensation for the medical expenses and the attorneys' fees were warranted.
Liberty Mut. Ins. Co. v Mercado (2025 NY Slip Op 00631)
February 4, 2025
The court considered facts surrounding a motor vehicle collision on April 15, 2019, in which the individual defendants, allegedly without reported injuries and no citations issued, sought medical treatment from the defendant medical providers. The plaintiffs, as no-fault insurance providers, denied claims for reimbursement made by the medical providers, which were assignees of the individual defendants, asserting that the individual defendants failed to complete required examinations under oath (EUOs) as a condition for coverage. The main issues decided included the justification for the EUOs and whether the defendants' noncompliance voided the insurance policy. The court held that the plaintiffs were justified in requesting the EUOs and that the individual defendants' failure to comply constituted a breach of a condition precedent to coverage, thereby affirming the denial of reimbursement claims.
Trapezius Diagnostic Chiropractic, P.C. v Adirondack Ins. Exch. (2025 NY Slip Op 50173(U))
January 17, 2025
The court considered the facts surrounding a no-fault benefits claim made by Trapezius Diagnostic Chiropractic, P.C. for medical services allegedly rendered due to injuries from a motor vehicle accident on November 4, 2017. Adirondack Insurance Exchange contended that the claim was barred by a prior declaratory judgment in which a different accident on November 14, 2017 was declared a "staged accident," relieving them of the obligation to provide coverage for related services. The primary issues decided included whether res judicata applied to bar the current claim and whether the evidence presented justifiably supported each party's motions for summary judgment. The court held that Adirondack failed to demonstrate that the current action was barred by res judicata, but also found that there was a material factual dispute regarding the date of the accident, thus denying Trapezius's cross-motion for summary judgment while affirming the denial of Adirondack's summary judgment motion.
Precision Acupuncture P.C. v State Farm Mut. Auto. Ins. Co. (2025 NY Slip Op 50021(U))
January 14, 2025
The court considered several key facts in this case, including the timely mailing of examination under oath (EUO) scheduling letters by the defendant, State Farm, and the plaintiffs' failure to appear for two scheduled EUOs. The main issues decided included whether the defendant's denial of claims was timely and if the plaintiff had effectively rebutted the defendant's arguments regarding the denial of one particular bill, which was denied after a missed EUO. The court held that the defendant's denial was indeed timely, as the time to deny remained tolled due to the pending EUO request when subsequent bills were submitted. As a result, the court granted the defendant's cross-motion for summary judgment, denied the plaintiff's motion, and dismissed the case with prejudice.
Fyzio PT, PLLC v Ocean Harbor Cas. Ins. Co. (2025 NY Slip Op 50103(U))
January 13, 2025
The court considered relevant facts including the plaintiff's claim for unpaid medical bills incurred by the claimant, Edouard Eguelino, and the defendant's assertion that the claimant failed to appear for required Examinations Under Oath (EUO) and Independent Medical Exams (IME). The main issues decided included whether the defendant had adequately established the claimant's non-appearance for the EUOs and IMEs and whether Florida or New York law applied to the case. The court found that the defendant failed to provide sufficient evidence from a person with personal knowledge of the nonappearances, and therefore did not meet its burden for summary judgment. Ultimately, the court denied the defendant's motion for summary judgment, allowing the case to proceed to trial to determine the facts surrounding the claimant's alleged failure to comply with preconditions for reimbursement.
Fyzio PT, PLLC v Ocean Harbor Cas. Ins. Co. (2025 NY Slip Op 50103(U))
January 13, 2025
The court considered several key facts, including the plaintiff's claim for $558.02 in unpaid medical bills for services rendered to claimant Edouard Eguelino and the defendant's assertion that the claimant failed to appear for scheduled Examinations Under Oath (EUOs) and Independent Medical Exams (IMEs). The main issues decided included whether the defendant could successfully argue the lack of coverage due to the claimant's alleged non-appearance and whether Florida law or New York law applied to the case. The plaintiff's argument noted the relevance of New York law, given the treatment and the accident location. Ultimately, the court held that the defendant failed to establish a prima facie case for summary judgment, as it did not provide admissible evidence demonstrating the claimant’s failure to appear for the appointments, resulting in the denial of the defendant’s motion for summary judgment and allowing the case to proceed to trial.
Williams v Kemper Independence Ins. Co. (2025 NY Slip Op 50101(U))
January 10, 2025
The court considered that the plaintiff was seeking $1,949.69 in unpaid medical bills related to services provided to Damally Caine, but failed to submit a completed No-Fault Application within the required time frame of thirty days following the alleged accident. The primary issues were whether the plaintiff had complied with the conditions precedent for coverage under the No-Fault Insurance Law and whether the defendant was entitled to summary judgment due to the plaintiff's failure to provide the necessary application. The court ruled that the failure to submit a completed No-Fault Application constituted a breach of condition precedent, precluding coverage for the claim. It found that the defendant had made a prima facie showing of entitlement to summary judgment, as the plaintiff did not establish any material issues of fact in opposition to the motion. Consequently, the court granted the defendant's motion for summary judgment, dismissing the complaint in its entirety.
Williams v Kemper Independence Ins. Co. (2025 NY Slip Op 50101(U))
January 10, 2025
In this case, the court considered relevant facts surrounding the failure of the plaintiff to submit a completed No-Fault Application within thirty days following an alleged accident, which the defendant argued precluded the plaintiff from receiving coverage for unpaid medical bills totaling $1,949.69. The main issue was whether the defendant's claim for a lack of timely submission of this application constituted a valid defense to the plaintiff's demand for payment. The court found that the defendant established a prima facie case by demonstrating the non-receipt of the necessary paperwork, while the plaintiff argued that the defendant could not invoke the thirty-day rule defense without issuing a timely denial of the claim. Ultimately, the court held that the failure to submit a completed No-Fault Application constituted a breach of a condition precedent to coverage, granting the defendant's motion for summary judgment and dismissing the plaintiff's complaint in its entirety.