No-Fault Case Law

A provider sued MVAIC for assigned first-party no-fault benefits for services rendered in May and June 2021. The parties stipulated that the claims were timely submitted to American Transit, which denied them because the policy had expired, that the provider then submitted them to MVAIC on December 15, 2021, and that MVAIC timely denied under the 45-day rule. The only issue at trial was whether the provider had reasonable justification for the delay under 11 NYCRR 65-3.3(e), and Civil Court found a reasonable excuse based on policy considerations about overburdened providers. The Appellate Term, First Department reversed, holding that the court could not disregard the strict filing time frames, which were intended to combat fraud and ensure prompt compensation. The provider's witness could not say when the provider contacted the referring physician, the provider did not respond to MVAIC's denials inviting a justification, and the cover letters did not explain the months of delay. Judgment was directed for MVAIC dismissing the complaint.

The plaintiff provider sued State Farm for assigned no-fault benefits, and the insurer moved for summary judgment on the ground that the provider failed to respond to verification requests within 120 days under 11 NYCRR 65-3.5(o). The court found that the insurer established its prima facie case and that the provider's owner affidavit did not show that the requested verification was provided or offer a reasonable justification for the failure to respond. The affidavit was internally contradictory about where the documents were mailed and lacked documentary proof of mailing, and the provider had also sent 197 pages of correspondence objecting to the requests and treating them as nullities. The court held that it was not improper to seek management agreements, W-2 forms, bank records and leases during verification to test licensing eligibility, and it found Government Employees Ins. Co. v Mayzenberg inapplicable to the verification stage. It refused to consider the provider's amended cross-motion served 18 months after the insurer's opposition, granted the insurer's motion and denied the cross-motion as moot.

Hartford Fire Insurance Company petitioned under CPLR article 75 to permanently stay arbitration of a claimed uninsured motorist benefits claim arising from an alleged hit-and-run collision between the claimant, who was riding a motorized scooter, and an unidentified motorcyclist. The claimant did not file written opposition by the court-ordered date, and Supreme Court granted the stay on her default. She moved under CPLR 5015 (a) (1) to vacate the default, which required a reasonable excuse and a potentially meritorious defense. She argued that she was hampered by the lack of certain medical records and a police report, but gave no explanation of her efforts to obtain them. The Appellate Division held this was not a reasonable excuse, did not reach the meritorious defense question, and affirmed the denial of vacatur.

Nostrand Drugs Rx, a pharmacy, sought reimbursement from Church Mutual for $2,343.20 in prescription medications dispensed to a patient injured in a September 2020 accident. An arbitrator denied the claim after a hearing and a master arbitrator confirmed that award. The pharmacy petitioned under CPLR article 75 to vacate the master arbitrator's award, and Supreme Court denied the petition. The Second Department affirmed, observing that the grounds for vacating a no-fault arbitration award are few and narrowly applied and that a master arbitrator's mere errors of law are insufficient to set an award aside. The pharmacy failed to demonstrate any statutory ground for vacatur, and its remaining contentions were either raised for the first time on appeal or not reached.

A provider, as assignee, sued Nationwide for first-party no-fault benefits, and the insurer moved for summary judgment based on the assignor's failure to appear for examinations under oath. The insurer's attorney submitted an affidavit describing the office's standard practices and procedures for mailing EUO scheduling letters and stated under penalty of perjury that he had personal knowledge those practices were followed. The Appellate Term held this was a prima facie showing that the notices were timely and properly mailed and that the assignor failed to appear at the initial and follow-up EUOs. The court also found that the insurer gave a specific objective justification for requesting the EUOs under 11 NYCRR 65-3.5 (e). Plaintiff raised no issue of fact in opposition, so the court reversed and granted the insurer's motion dismissing the complaint.

A provider sued for first-party no-fault benefits, and the insurer's unopposed motion for summary judgment dismissing the complaint was denied by Civil Court. The Appellate Term, First Department reversed. It held that the insurer made a prima facie showing that it timely and properly mailed notices for examinations under oath and that the plaintiff failed to appear at the initial and follow-up EUOs. Failure to attend EUOs violates a condition precedent to coverage. The plaintiff's argument that the insurer failed to show the EUO requests were reasonable was raised for the first time on appeal and was unpreserved. Summary judgment dismissing the complaint was granted.

A physical therapy provider sued Allstate as assignee to recover no-fault benefits, and Allstate moved for summary judgment on the statutory intoxication exclusion and a fee-schedule defense. The court explained that an insurer relying on the intoxication exclusion must prove with admissible evidence both that the injured person was intoxicated or impaired and that the injuries resulted from operating a vehicle in that condition. Allstate relied on uncertified, unauthenticated medical records and a police accident report without any evidentiary foundation, unlike the certified hospital records and toxicology report in the case it cited. The assignor's examination under oath also denied being intoxicated. The court further held that Allstate had not shown by admissible evidence that the charges exceeded the fee schedule. The motion was denied in its entirety, with no finding of intoxication, and the insurer was left to carry its burdens at trial.

The provider sued Allstate Insurance Company to recover $1,988.70 in no-fault benefits for services to its assignor after a September 2023 accident. The defendant moved to dismiss for lack of jurisdiction or for summary judgment, asserting that the policy was issued by Allstate New Jersey Property and Casualty Insurance Company, a separate entity that does not do business or maintain an office in New York City, and that it had been improperly served. The court found that the defendant established prima facie that it did not issue the policy and was not a proper party. The provider offered only conclusory allegations about the identity of the issuer and the relationship between the companies, which did not raise a triable issue of fact. The motion was granted and the complaint dismissed.

The provider sued as assignee for no-fault benefits and both sides moved for summary judgment. The insurer received the bill in September 2019, scheduled an EUO, and the provider appeared in October 2019. Because of insufficient testimony, the insurer then requested additional written verification and ultimately denied the claim in March 2020 after the provider did not respond within 120 days. The provider argued that the statute did not address post-EUO verification requests and that holding the EUO ended the tolling. The court held that post-EUO verification requests are permissible and continue the tolling, and that the provider's later statement of intent to respond was not a response. It granted the insurer's motion and denied the provider's cross-motion.

The plaintiff provider sued Maya Assurance as assignee of its patient for $408.16 in no-fault benefits for injections and arthrocentesis rendered on May 17, 2022. The insurer moved for summary judgment, claiming the plaintiff ignored two additional verification requests mailed July 7 and August 5, 2022, seeking a signed NF-3 and assignment of benefits, and that its January 25, 2023 NF-10 denial was proper under 11 NYCRR 65-3.5 (o). The court agreed the requested items were rationally related to the claim, but held the insurer failed to establish proper mailing of the first request because its adjuster's affidavit did not describe the office mailing procedures for that request. The NF-10 also stated a different mailing date than the insurer asserted, raising a further factual issue. The court rejected the plaintiff's argument that requests had to be sent separately to both the provider and its attorney, and denied the motion for summary judgment, leaving the case for trial.