No-Fault Case Law

The court considered whether the defendant's law firm should be disqualified in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant submitted sufficient proof to show that the plaintiff had failed to appear for scheduled examinations under oath, and whether the law firm representing defendant should be disqualified based on the attorney/witness rule. The holding of the case was that the defendant had submitted sufficient proof to show that the plaintiff had failed to appear for scheduled examinations under oath, and that the law firm representing the defendant did not need to be disqualified. Therefore, the judgment was affirmed.

The relevant facts considered by the court were that the plaintiff, Natural Therapy Acupuncture, P.C., was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co., and the defendant had denied the claims at issue on the ground that the plaintiff had failed to comply with a condition precedent to coverage, in that they had failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided by the court was whether the defendant's EUO requests were justified and whether the plaintiff had failed to comply with the requests. The holding of the case was that the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, as the defendant had established that the EUO scheduling letters and the denial of claim forms had been timely mailed and the plaintiff had failed to appear for the EUOs, and the plaintiff's objections regarding the EUO requests were not considered as they had not responded in any way. Therefore, discovery relevant to the reasonableness of the EUO requests was not necessary for the plaintiff to oppose the defendant's motion.

The relevant facts of the case were that an insurance company had timely mailed verification requests to a medical care provider, but had not received the requested verification. The main issue decided by the court was whether the insurance company had to prove that the copies of the verification letters had not been tampered with or altered. The court held that there was nothing in the record requiring the insurance company to prove that the copies had not been tampered with, and that as a result, the medical care provider's action was premature. Therefore, the court reversed the findings in favor of the medical care provider and granted the insurance company's cross motion for summary judgment dismissing the complaint.

The main issue in Matter of Unitrin Direct/Warner Insurance Company v Joseph Brand was whether arbitration should be permanently stayed regarding a claim for supplementary uninsured/underinsured motorist benefits. The appellate division affirmed the order granting the petition, holding that this dispute was a contractual matter to be governed by the conflict of law rules relevant to contracts, not torts. The court found that New York had more significant contacts with the parties and the contract, and that SUM coverage was not triggered under New York law because the offending vehicle was not underinsured. Brand's reliance on Florida law was found to be inapplicable in this case, as the relevant insurance contract was written to conform to the laws, rules, and regulations of New York State, and was obtained in New York by Brand, a New York resident. The court also rejected Brand's contention that Unitrin's payment of first-party benefits constituted an agreement that Florida law controls.

The court considered the plaintiff's claim for reimbursement of $844.13 for medical services rendered to Mr. Jacques Gladys. State Farm Mutual Automobile Insurance Co. denied the claim on the basis that the medical provider failed to appear for two scheduled examinations under oath. State Farm Mutual Automobile Insurance Co. moved for summary judgement on the ground that the medical provider failed to appear for two scheduled examinations under oath and is therefore in breach of a condition precedent to coverage. Michael Sirignano's affirmation was determined to be sufficient to prove the provider's nonappearance for the examinations. The affidavit provided by Sirignano and his personal knowledge of those failed appointments are sufficient and outweighed by the plaintiff's other arguments, resulting in that State Farm Mutual Automobile Insurance Co. be entitled to summary judgment.

Relevant facts: Ana Rodriguez was insured under a policy of car insurance issued by New York Central Mutual Fire Insurance Company. In March 2011, she was injured and received treatment at Mount Sinai Hospital. Mount Sinai's biller issued a request for payment of the bill for the treatment shortly after treatment was rendered. New York Central allegedly received these records twenty days later, and they denied the claim on a Form NF-10 less than 30 days after receiving these records. They ignored a subsequent request for payment made by Mount Sinai in March 2012. Main issues decided: Whether the 30-day period for New York Central to pay or deny the claim began in March 2012, rather than December 2011 when the treatment was initially rendered. The court considered the regulations for no-fault claims under New York's insurance scheme and determined when the 30-day period begins. Holding: The Supreme Court erred in denying Mount Sinai's motion for summary judgment on the complaint and in granting New York Central's cross-motion for summary judgment dismissing the complaint. The 30-day period for New York Central to pay or deny the claim did not begin to run until March 26, 2012, when Mount Sinai submitted the Form NF-5. New York Central was precluded from raising defenses because it did not pay or deny the claim within 30 days after receiving the NF-5. Therefore, Mount Sinai was entitled to summary judgment on the complaint. The complaint predicated on New York Central's failure to pay or deny the March 2012 claim within 30 days was not entitled to summary judgment dismissing the complaint. The ruling was reversed.

The court considered a case in which Okslen Acupuncture P.C. sought to recover first-party no-fault benefits for acupuncture services provided to a patient. The main issue was whether the defendant, Travco Ins. Co., timely and properly denied the claim, and whether the amount sought for reimbursement was greater than that authorized by the workers' compensation fee schedule. The court held that the defendant's affidavits established that the claim was properly denied, and that the plaintiff failed to raise a triable issue with respect to the denial or the calculation of the fee. Therefore, the defendant's motion for summary judgment dismissing the claim was affirmed.

The main issue in the case of Optimal Well-Being Chiropractic, P.C. v Infinity Ins. Co. was whether the plaintiff, as the assignee of an injured individual, was entitled to recover first-party no-fault benefits from the defendant. The defendant argued that a conflict-of-law analysis required the application of Pennsylvania law, under which there was a lack of coverage due to the rescission of the automobile insurance policy in question. The defendant issued the automobile insurance policy in Pennsylvania to the insured, for a vehicle which was purportedly garaged in Pennsylvania, and the only connection between the policy and New York State was that the plaintiff's assignor was injured while riding in the insured's vehicle in New York. The court ultimately held that the rescission of the insurance policy was effective with respect to the plaintiff's assignor, as the assignor's actions made him complicit in the fraud perpetrated by his mother in obtaining the policy. Consequently, the judgment in favor of the plaintiff was reversed, the plaintiff's motion for summary judgment was denied, and the defendant's cross motion for summary judgment dismissing the complaint on the ground of lack of coverage due to the rescission of the insurance policy was granted.

The court considered an action by a medical provider to recover assigned first-party no-fault benefits, where the defendant insurer had denied the claims based on a lack of medical necessity. The main issue decided was whether the defendant's denial of the claims was appropriate and whether there was a triable issue of fact regarding the medical necessity of the services at issue. The court held that the defendant failed to articulate a sufficient basis to strike the plaintiff's findings in their favor and that there was a triable issue of fact regarding the medical necessity of the services. Therefore, the court affirmed the order, with the only remaining issue for trial being the medical necessity of the services.

The relevant facts considered by the court included a motion for summary judgment by the plaintiff to recover assigned first-party no-fault benefits, as well as a cross motion by the defendant to dismiss the complaint based on a lack of medical necessity. The main issue decided was whether the defendant had properly denied the claim at issue based on a lack of medical necessity, and whether there was a triable issue of fact regarding the medical necessity of the supplies at issue. The holding of the case was that the court affirmed the denial of the plaintiff's motion for summary judgment and found that there was a triable issue of fact regarding the medical necessity of the supplies at issue, therefore the only remaining issue for trial was medical necessity. The order was affirmed with costs.