No-Fault Case Law

The case involves an action to recover no-fault benefits under two separate policies of automobile insurance. The appellant, QBE Insurance Corporation, appealed from a judgment entered in favor of the plaintiffs, New York Hospital Medical Center of Queens, in the sum of $66,682.29. The Supreme Court denied the defendant's cross motion for summary judgment and granted the plaintiff's motion for summary judgment in connection with the first and second causes of action. The main issue of the case was whether the plaintiffs were entitled to recover no-fault benefits under both insurance policies. The court held that the plaintiffs were entitled to recover no-fault benefits on the second cause of action, related to the claim submitted by Westchester Medical Center. However, the court modified the judgment to dismiss the first cause of action, as the defendant, QBE Insurance Corporation, had established that payment on the claim made by the plaintiff New York Hospital Medical Center of Queens was not overdue due to outstanding verification requests.

The court considered the mandatory arbitration process as the sole available remedy to determine issues of coverage between insurance carriers and Motor Vehicle Accident Indemnification Corporation (MVAIC). The appellant, Farmers Insurance Company, failed to participate in the arbitration proceeding, seek an adjournment, or file a petition to vacate the arbitration award regarding the alleged cancellation of the insurance policy. The main issues decided were the obligation of Farmers Insurance Company to provide coverage for the accident and the preclusive effect of the arbitration decision. The holding of the court was that appellant had a full and fair opportunity to contest the decision, and failed to do so, therefore, the order finding Farmers Insurance Company obligated to provide coverage for the accident was affirmed.

The court considered the matter of two arbitration awards that were vacated and remanded for a new arbitration before a new arbitrator. The main issue decided was whether the arbitration awards, rendered in compulsory arbitration, were irrational or contrary to settled law, and therefore should have been confirmed. The court held that the arbitral awards were not irrational or contrary to settled law, and therefore should have been confirmed. It was also determined that the respondent insurer's disclaimer, based strictly upon primacy of coverage, was not so absolute or unequivocal as to constitute a repudiation of the policy. The court held that the petitioner failed to comply with the conditions precedent to coverage found in the implementing no-fault regulations.

The court in this case considered an action to recover no-fault benefits under a policy of automobile insurance. The plaintiff, Westchester Medical Center, as assignee of Arianna Thrasher, appealed from an order of the Supreme Court that denied its motion for summary judgment on its first cause of action. The court held that the plaintiff made a prima facie showing of entitlement to judgment by submitting evidence that the prescribed billing form was received by the respondent insurer and failed to pay or deny the claim within the requisite 30-day period. The court also held that the respondent failed to raise a triable issue of fact in opposition to the appellant's prima facie showing. The respondent's contention of a complete absence of coverage that could be asserted as a basis for disclaimer was deemed improper as it was raised for the first time on appeal. The court reversed the order, granting the plaintiff's motion for summary judgment on its first cause of action.

The court considered the fact that the plaintiff provider was seeking to recover assigned first-party no-fault benefits from the defendant insurance company. The main issue decided was whether the defendant had timely and properly denied the claims at issue on the ground that the plaintiff had failed to comply with a condition precedent to coverage by failing to appear for duly scheduled examinations under oath. The holding of the court was that the defendant had proven that it had mailed its EUO scheduling letters and denial of claim forms in accordance with its standard office practices and procedures, and that the plaintiff's objections regarding the EUO requests would not be heard since the plaintiff did not claim to have responded in any way to the EUO requests. Therefore, the court affirmed the order of the Civil Court granting the defendant's motion for summary judgment dismissing the complaint.

The court considered a case in which Alev Medical Supply, Inc., as the assignee of Kecia Daniely, appealed the dismissal of their complaint seeking first-party no-fault benefits from Government Employees Insurance Company. The trial was limited to the issue of the defendant's defense of lack of medical necessity, and ultimately, the court found in favor of the defendant, dismissing most of the plaintiff's claims. The only remaining claim was for the recovery of $330 for a massager and a Thermophore. On appeal, plaintiff raised evidentiary objections, specifically challenging the admissibility of defendant's doctor's testimony as hearsay. However, the court affirmed the judgment, ruling that the Civil Court properly overruled plaintiff's hearsay objection and that the plaintiff's remaining contentions lacked merit. Therefore, the judgment was affirmed in favor of the defendant.

The main issue in this case was whether the defendant, New York Central Mutual Fire Insurance Company, had timely denied the two claims at issue on the ground of lack of medical necessity. The defendant argued that they had timely mailed their denial of claim forms, which denied the claims. However, conflicting medical expert opinions were presented by the parties, demonstrating the existence of a triable issue of fact as to whether there was a lack of medical necessity for the services provided. The court ultimately held that the order denying the defendant's motion for summary judgment dismissing the complaint was affirmed, as the conflicting expert opinions were sufficient to demonstrate the existence of a triable issue of fact.

The court considered the facts of a motor vehicle accident involving passengers in a U-Haul truck, for which the U-Haul was insured by Repwest Insurance Company. The passengers allegedly refused medical attention at the scene of the accident and later sought treatment for injuries sustained from the collision. Repwest Insurance Company (Repwest Ins.) sent requests for examinations under oath (EUOs) to the Defendant Claimants, but they failed to appear. As a result, Repwest Ins. denied all no-fault coverage for the claims submitted by the medical provider defendants based on the failure to attend the scheduled EUOs. The main issue decided by the court was whether the Defendant Claimants were entitled to no-fault coverage, and the holding of the case was that the Answering Defendants, Comprehensive Psychological Evaluation, P.C. and Orthoplus Products, Inc., were not entitled to no-fault coverage as they failed to attend the EUOs. The court granted Repwest Ins.'s motion for summary judgment against the Answering Defendants.

The relevant facts considered by the court were that the plaintiff, Flushing Traditional Acupuncture, provided acupuncture services to an injured individual who was covered by a no-fault insurance policy with Kemper Insurance Company. Subsequently, Kemper filed a declaratory judgment action against the plaintiff and other providers, alleging breach of the insurance policy for failing to appear for scheduled examinations under oath. The Supreme Court entered a judgment declaring that the plaintiff and other providers were not entitled to recover no-fault benefits. The main issue decided was whether the present action by the plaintiff to recover assigned first-party no-fault benefits was barred under the doctrine of res judicata due to the prior judgment entered by the Supreme Court. The holding of the court was that the present action was indeed barred by the doctrine of res judicata, as any judgment in favor of the plaintiff would destroy or impair rights or interests established by the Supreme Court judgment. Therefore, the court affirmed the order granting Kemper's motion to dismiss the complaint.

The court considered an action for a declaration that the plaintiff has no obligation to pay certain no-fault claims. The key legal issue was whether the defendants were entitled to recover no-fault benefits, as the failure to comply with the provision of an insurance policy requiring the insured to submit to an examination under oath is a material breach of the policy, precluding recovery of the policy proceeds. The court held that the plaintiff insurer established as a matter of law that it twice duly demanded an examination under oath from the appellants' assignor, who failed to appear, and that the plaintiff issued a timely denial of the claims arising from the appellants' treatment of the assignor. The appellants failed to raise a triable issue of fact as to the propriety of the demand for the examination under oath or whether the assignor actually appeared at the examination, and also failed to demonstrate that discovery might lead to relevant evidence or that the facts essential to justify opposition to the motion were exclusively within the knowledge and control of the movant. Therefore, the judgment was affirmed in favor of the plaintiff insurer.