No-Fault Case Law

The court considered an appeal from an order denying defendant's motion for summary judgment in a case seeking recovery of first-party no-fault benefits. The main issue decided was whether the defendant-insurer established the proper and timely mailing of the denial of claim forms at issue, which would warrant summary dismissal. The court held that the action was not ripe for summary dismissal because the defendant failed to establish the proper and timely mailing of the denial of claim forms, as the affidavit submitted by the defendant lacked probative value and failed to set forth the basis of the affiant's personal knowledge of the internal mailing practices and procedures of the defendant during the pertinent period. Therefore, the court affirmed the order denying defendant's motion for summary judgment.

The relevant facts considered by the court were that the defendant, an insurance company, had denied the plaintiff's claim for first-party no-fault benefits on the ground of lack of medical necessity. The insurance policy's coverage limits had been exhausted through payment of no-fault benefits in satisfaction of arbitration awards rendered in favor of other healthcare providers, in compliance with the priority of payment regulation. The main issue decided by the court was whether the defendant was entitled to summary judgment dismissing the action for first-party no-fault benefits. The holding of the court was that the defendant-insurer made a prima facie showing of entitlement to summary judgment, and the plaintiff failed to raise a triable issue in opposition. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the plaintiff's claim for first-party no-fault benefits, and the defendant's motion for summary judgment dismissing the complaint based on the assignor's failure to appear at scheduled examinations under oath (EUOs). The main issues decided were whether the defendant established its entitlement to judgment as a matter of law and whether an insurer is required to set forth objective standards for requesting an EUO. The court held that the defendant had timely mailed the EUO scheduling letters, that the assignor had failed to appear for the EUOs, and that the denial of the claim form had been timely mailed. The court also held that there is no provision of No-Fault Regulation 68 that requires an insurer to set forth objective standards for requesting an EUO. The holding was that the defendant's motion for summary judgment dismissing the complaint was granted.

Plaintiff, a medical provider, sued defendant, an insurance company, to recover unpaid first-party no-fault benefits for medical services it provided to a car accident injury victim. Defendant rejected part of plaintiff's claim, arguing that the claim exceeded the fee schedule limit under New Jersey law. The main issue is whether the insurance company is obligated to pay the full bill submitted by the medical provider, even if it exceeds the fee schedule. The court found in favor of the defendant, holding that the medical provider was bound by New Jersey's fee schedule because they are located outside of New York; and that the New York Statute intended to reduce the amount paid by insurers for medical services. Therefore, plaintiff was not entitled to recover the full amount of the bill.

The court considered the fact that the defendant-insurer had mailed notices for independent medical examinations (IMEs) to plaintiff's assignor, and that the assignor failed to appear. The main issue decided was whether the defendant was entitled to summary judgment dismissing the action for first-party no-fault benefits. The holding of the court was that the defendant-insurer had made a prima facie showing of entitlement to summary judgment by establishing that it had timely and properly mailed the IME notices, and that the assignor failed to appear. The court also found that the plaintiff did not raise a triable issue in opposition to the defendant's evidence, and therefore granted the defendant's motion for summary judgment dismissing the complaint.

The main issues in this case involved an arbitration in which respondent New Century Acupuncture P.C. sought reimbursement from petitioner Country-Wide Insurance Company for healthcare services provided to an assignor, William Dew, following a motor vehicle accident. Country-Wide alleged that New Century was fraudulently incorporated and actually owned or controlled by an individual who had pleaded guilty to conspiracy to commit mail fraud and health care fraud. Arbitrator Rosenberger issued an Arbitration Award in favor of New Century, but Country-Wide argued that the award should be vacated based on the arbitrator's failure to disclose a relationship with New Century and its attorneys. The court held that the failure of the arbitrator to disclose his connection to New Century's attorneys mandated vacatur of the Arbitration Award, and granted the petition to vacate the award.

The court considered the fact that the offending vehicle in a no-fault arbitration was insured by Global Liberty Insurance of New York subsequent to the respondent's coverage. It was determined that the subsequent coverage terminated the respondent's coverage of the same vehicle as of the effective date and hour of Global's coverage, irrespective of whether the respondent had otherwise complied with the cancellation requirements of the Vehicle and Traffic Law. The main issues decided were that the respondent failed to demonstrate that it had properly cancelled its policy, and that the arbitration award was in excess of the arbitrator's authority. The holding of the case was that the arbitration award in favor of the petitioner was vacated, and the respondent's cross petition seeking to vacate the arbitration award was granted.

The main facts considered by the court were that defendant moved for summary judgment dismissing the complaint, and plaintiff cross-moved for summary judgment. The main issue to be decided was whether the first cause of action should have been dismissed as premature. The holding of the court was that the 30-day period within which defendant was required to pay or deny the claim did not begin to run, and thus the first cause of action should have been dismissed as premature. The court ultimately reversed the order and granted the branch of defendant's motion seeking summary judgment dismissing the first cause of action.

The court considered whether a provider could recover assigned first-party no-fault benefits from an insurance company. The main issue was whether the action was premature since the provider had not responded to the insurance company's requests for additional verification. The court held that the action was indeed premature because the provider had not provided all the verification requested by the insurance company, and therefore the 30-day period within which the insurance company was required to pay or deny the claims did not begin to run. The court also found that the provider's remaining contention was not properly before the court and declined to consider it. Therefore, the court affirmed the denial of the provider's motion for summary judgment and granted the insurance company's cross motion for summary judgment dismissing the complaint.

The court considered a motion to dismiss a complaint by a provider seeking to recover assigned first-party no-fault benefits, on the ground that the Civil Court lacked personal jurisdiction over the defendant insurance company. The defendant provided affidavits stating that they were a Pennsylvania company not licensed to do business in New York, with no offices, bank accounts, agents, or real property in New York, and did not contact or solicit business in New York. The plaintiff's opposition to the motion consisted of only an unverified complaint and a conclusory affirmation by the plaintiff's counsel. The main issue decided was whether the Civil Court properly granted the defendant's motion to dismiss the complaint based on lack of personal jurisdiction. The holding of the court was that the order granting the defendant's motion to dismiss was affirmed, as the plaintiff did not provide sufficient evidence to warrant jurisdictional discovery, and plaintiff's argument that essential jurisdictional facts might exist was not supported by tangible evidence.