Court of Appeals
Nov 24, 2025
2025 NY Slip Op 06527
Provider prevailed
An insurer may not deny no-fault reimbursement for alleged professional misconduct short of ceding control to an unlicensed party. The Court of Appeals answered a certified question in the provider's favor after a federal court granted the insurer summary judgment declaring the provider ineligible because of paid patient referrals. Deferring to DFS's rational interpretation of 11 NYCRR 65-3.16 (a) (12), the majority distinguished foundational licensing requirements from professional discipline under Education Law § 6530 (18) and 8 NYCRR 29.1 (b) (3), which does not itself terminate licensure. The majority left open when a kickback scheme constitutes prohibited surrender of control; a dissent would permit denial for misconduct functionally equivalent to the defects in Mallela and Carothers.
Court of Appeals
Jun 11, 2019
2019 NY Slip Op 04643
Insurer prevailed
An insurer need not prove common-law fraud to deny reimbursement to a medical corporation improperly controlled by nonphysicians. The Court of Appeals affirmed the order sustaining dismissal after a jury found that unlicensed persons controlled the provider. Under Mallela and 11 NYCRR 65-3.16 (a) (12), willful and material violations of licensing requirements suffice; fraudulent intent or conduct tantamount to fraud need not be separately found. Inflated leases and transfers of profits supported the control finding under Business Corporation Law §§ 1507 and 1508, rather than mere fee splitting. Any error in admitting nonparties' repeated Fifth Amendment invocations and charging an adverse inference was harmless under CPLR 2002; the court left open whether such an inference is permissible.
Court of Appeals
May 1, 2018
2018 NY Slip Op 03093
Insurer prevailed
No-fault claims against a self-insurer are subject to the three-year statute of limitations under CPLR 214 (2). The provider sought assigned benefits for treatment of a passenger injured on the self-insurer's bus. Because no insurance contract required payment, the obligation arose wholly from the Vehicle and Traffic Law and Insurance Law. First-party benefits were unknown at common law, making the liability statutory rather than contractual under CPLR 213 (2). The Court of Appeals reversed the Appellate Division order and granted dismissal as time-barred. A separate concurrence emphasized that the limitations period for insurers issuing policies remained unresolved, and three judges dissented in favor of a uniform six-year period.
Court of Appeals
Jun 14, 2016
2016 NY Slip Op 04658
A health insurer cannot obtain direct reimbursement from a no-fault insurer as an assignee under 11 NYCRR 65-3.11 (a). The health insurer paid medical bills allegedly payable under the injured claimant's automobile policy and sued after receiving an assignment of the claimant's rights. The Court of Appeals affirmed dismissal under CPLR 3211 (a) (7), in favor of the no-fault insurer. The majority concluded that the claimant had already assigned no-fault rights to the medical providers and had no remaining rights to assign, and that the regulation permits direct payment only to the insured or an assignee providing health care services. A separate concurrence rejected equitable subrogation; the dissent would have allowed that claim to proceed.
Court of Appeals
Mar 31, 2016
2016 NY Slip Op 02473
Insurer prevailed
No-fault insurers are not required to reimburse facility fees charged by accredited office-based surgery practices. The provider separately billed professional services and fees for use of its location, equipment and support staff; the insurers paid the professional charges but declined the facility fees. The Court of Appeals affirmed summary judgment declaring that the insurers had no obligation to pay those fees. Insurance Law § 5102 (a) (1) subjects reimbursable expenses to Insurance Law § 5108, and the authorized schedules provide facility fees for hospitals and ambulatory surgery centers, but not office-based surgery practices. Nor does 11 NYCRR 68.5 authorize recovery: facility fees are expenses associated with services, rather than professional health services themselves.
Court of Appeals
Jul 1, 2015
2015 NY Slip Op 05626
Insurer prevailed
A statutory SUM endorsement excludes police vehicles from "motor vehicle" coverage unless the endorsement specifically provides otherwise. An injured police passenger sought SUM benefits under the driver's personal automobile policy after an underinsured vehicle struck their police car. Following Amato, the majority applied Insurance Law § 3420 (f) (2) (A) and Vehicle and Traffic Law § 388 (2), retained that precedent under stare decisis, and distinguished coverage afforded to named insureds. The Court of Appeals reversed and granted the insurer's petition to permanently stay arbitration; three judges dissented, favoring coverage under the driver's endorsement. The majority left open any available remedies under the No-Fault Law, a lawsuit, or the claimant's own insurance.
