Appellate Division, First Department
Jul 9, 2026
2026 NY Slip Op 04363
Provider prevailed
The insurer failed to undermine the arbitrators' conclusions on the IME cut-off date and verification tolling. The Appellate Division, First Department, affirmed denial of the CPLR article 75 petition, although it was timely under CPLR 7511 (a) because it followed required master arbitration review under 11 NYCRR 65-4.10 (a). The arbitrator used the provider's receipt of termination notice as the cut-off; the insurer did not address that ground or reliance on an Insurance Department opinion requiring timely denial. The insurer also failed to challenge findings that requested verification had been supplied and the unanswered request sought previously furnished information. Under 11 NYCRR 65-3.8 (a) (1), the arbitrator reasonably found tolling ended. Both awards had a rational basis.
Appellate Division, First Department
Jun 23, 2026
2026 NY Slip Op 03933
Insurer prevailed
The claimant failed to provide the sworn factual notice required for a hit-and-run UM/SUM claim, permitting disclaimer and a permanent stay. The SUM endorsement unambiguously replaced the policy's UM coverage and tracked Insurance Law § 3420 (f) and 11 NYCRR 60-2.3 (f). Counsel's claim letter and sworn NF-2 application did not identify a hit-and-run accident, establish physical contact, or address the offending vehicle's unascertainable identity or efforts to identify it. An accident report supplied over three months after the accident also omitted the hit-and-run characterization, which first appeared in the arbitration demand nearly 11 months later. The Appellate Division, First Department, affirmed the order permanently staying arbitration.
Appellate Division, First Department
Apr 2, 2026
2026 NY Slip Op 02035
The responding insurer's post-decision submission of a coverage disclaimer defeated jurisdiction over the loss-transfer arbitration. The petitioning no-fault insurer sought reimbursement under Insurance Law § 5105 after paying its insureds' claims. The other vehicle's insurer had disclaimed because the vehicle was not listed as a covered auto, but submitted its disclaimer to Arbitration Forums Inc. only after the award, through a Post-Decision Inquiry. The Appellate Division, First Department, reversed confirmation, granted vacatur, and dismissed the petition. The submission satisfied AFI rule 3-9 and defeated jurisdiction under AFI rule 2-4. Under 11 NYCRR 65-4.11 (a) (6), the good-faith lack-of-coverage defense made mandatory arbitration inapplicable absent that insurer's specific written consent.
Appellate Division, First Department
Dec 2, 2025
2025 NY Slip Op 06648
Provider prevailed
An insurer's admission in its motion papers that it received the claim may establish a provider's prima facie case at trial. The Appellate Division, First Department, reversed the Appellate Term's order and reinstated the provider's judgment after a nonjury trial. The insurer's admission was admissible without a witness, but its affidavit statements concerning verification requests could not serve as evidence in chief. Although the rule of completeness ordinarily would permit those statements, the insurer made no offer of proof and did not preserve that issue; it also did not argue business-record admissibility. Having conceded that it neither paid nor denied within 30 days, the insurer bore the burden of proving that verification requests were sent, rather than requiring the provider to disprove mailing.
Appellate Division, First Department
Oct 30, 2025
2025 NY Slip Op 06022
Insurer prevailed
A claimant's failure to subscribe EUO transcripts violates a condition precedent to no-fault coverage and warrants denial of the claim. The Appellate Division, First Department, affirmed the order, insofar as appealed from, granting the insurer summary judgment against the appealing providers. Their arguments concerning contract performance, willfulness, and untimely subscription demands were unpreserved and alternatively rejected. Following Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, willfulness principles governing liability policies did not apply. The subscription demands were sent after 9 and 14 business days, within 11 NYCRR 65-3.5 (a) and (b)'s 15-business-day period. Subscribed transcripts supplied years later did not establish compliance; 11 NYCRR 65-3.8 (b) (3) permitted denial after 120 days without verification or a valid written excuse.
Appellate Division, First Department
Apr 3, 2025
2025 NY Slip Op 02025
Provider prevailed
The insurers' EUO-based summary judgment motion was premature because they had not disclosed their objective justification for the EUOs. The insurers sought a declaration of no obligation to pay the provider's bills, alleging nonappearance and refusal to produce a knowledgeable individual. Under 11 NYCRR 65-3.5 (e), their criteria for requiring EUOs were essential to the provider's opposition and exclusively within their knowledge and control. They had not fully answered discovery seeking those standards. The Appellate Division, First Department, reversed, denied the motion and vacated the declaration. Whether the no-coverage defense was subject to preclusion remained undecided pending determination of the EUO rationale.
