No-Fault Case Law

The relevant facts considered by the court in this case include a dispute over payments for acupuncture services rendered by the plaintiff to its assignor. The defendant had partially paid for some sessions at a reduced rate and denied payment for others due to the assignor's failure to attend scheduled independent medical examinations (IMEs). The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint based on the assignor's failure to attend IMEs and the reduced reimbursement for sessions. The holding of the court was that the defendant was entitled to summary judgment dismissing the complaint with regard to the claims for which it had denied reimbursement based on the assignor's failure to attend IMEs, but it was not entitled to summary judgment for unpaid portions of the remaining bills based on a different reason. The order from the Civil Court was modified to reflect these conclusions.

The relevant facts considered by the court in Kuzma v Protective Ins. Co. involved the plaintiff's claim for disability benefits under an insurance policy after being injured in a motor vehicle accident while working as a driver for Fed Ex. The defendant, Protective Insurance Company, denied the plaintiff's claim for benefits. The main issues decided by the court were whether the defendant's motion for summary judgment should be granted and whether the contractual statute of limitations in the insurance policy was unconscionable. The court held that the defendant's motion for summary judgment was denied, as the contractual statute of limitations in the insurance policy was procedurally and substantively unconscionable and would not be enforced. The court also denied the defendant's motion to dismiss the complaint for failure to state a cause of action.

The main issues that the court considered in this case were whether the provider was entitled to recover assigned first-party no-fault benefits and whether the insurance company's denial of certain claims was without merit as a matter of law. The court held that while the provider demonstrated that the insurance company had not paid their claims, they failed to show that the basis for the denial of several specific claims was conclusory, vague, or without merit. As a result, the court denied the provider's motion for summary judgment. Additionally, the court declined to grant the insurance company's cross motion for summary judgment dismissing the complaint due to insufficient evidence submitted in admissible form. The court reversed the judgment, vacated the part of the order that granted the provider's motion for summary judgment, and denied the provider's motion. The court left undisturbed the implicit denial of the insurance company's cross motion for summary judgment.

The relevant facts of the case involved two related subrogation actions to recover insurance benefits paid by the plaintiff's insured in actions Nos. 1 and 3 and a related action to recover damages for personal injuries (action No. 2). Providence Washington Insurance Company appealed from an order denying its motion to dismiss a counterclaim and granted the cross motion of the defendants for an award of costs and an attorney's fee against it. The court decided that the counterclaim against Providence "cannot effect an affirmative recovery," and therefore should have been dismissed. The court also decided that the defendants failed to demonstrate that Providence's conduct was frivolous and granted an attorney's fee against it. The holding of the case was that the order was therefore reversed, granting that branch of Providence's motion to dismiss the counterclaim, and denied the defendants' cross motion for an award of costs and a fee against Providence.

The main issue in the case was whether the plaintiffs were entitled to recover no-fault insurance medical payments under two insurance policies. The court considered whether the defendant insurer failed to pay or deny the claims within the requisite 30-day period, as required by Insurance Law § 5106 and 11 NYCRR 65-3.8[a][1]. The holding of the case was that the Supreme Court should have denied the plaintiffs' motion for summary judgment on the complaint due to the presence of triable issues of fact raised by the defendant in opposition to the motion. The court also declared that the Supreme Court properly denied the defendant's cross motion for summary judgment, and that there was no reasonable justification offered by the defendant to renew its cross motion for summary judgment.

The relevant facts considered by the court were that Mount Sinai Hospital and New York Presbyterian Hospital sued Government Employees Insurance Company for no-fault medical payments. The main issue in the case was whether the hospitals had demonstrated that the necessary billing forms had been mailed to and received by the defendant and that the defendant had failed to either pay or deny the claim within the requisite 30-day period. The holding of the court was that the defendant raised a triable issue of fact as to whether it issued a denial of claim form dated April 2, 2008, to the hospital, so the Supreme Court should have denied the hospital's motion for summary judgment on its fourth cause of action.

The relevant facts considered by the court in Mount Sinai Hospital v State Farm Mutual Automobile Insurance Company were that the hospital rendered health services to Dolly Rahima during a period following a car accident and that the hospital sought payment from State Farm Mutual Automobile Insurance Company for these services. The main issue decided by the court was whether the insurer had failed to pay or issue a timely denial of the claim, thus precluding them from interposing a defense. The holding of the case was that the hospital's motion for summary judgment was granted, as the court found that the insurer neither paid nor issued a timely denial of the claim, and that the injuries sustained by Rahima arose from a reflexive action in a motor vehicle accident and did not "flow directly and immediately from an intended act." Therefore, the insurer was ordered to pay the hospital for the health services provided to Rahima.

The relevant facts considered by the court in this case were that Jesa Medical Supply, Inc. was seeking to recover first-party no-fault benefits for supplies provided to their assignor. The defendant argued that there was no coverage for the accident because it was staged. The main issue decided was whether the plaintiff had established a prima facie case for summary judgment, and whether the defendant had raised a triable issue of fact. The holding of the case was that the plaintiff's motion for summary judgment should have been denied, as the defendant's investigator's affidavit demonstrated a founded belief that the alleged injuries did not arise out of an insured incident. Therefore, the order was reversed and plaintiff's motion for summary judgment was denied.

The main issue in this case was whether a provider could recover first-party no-fault benefits for services rendered by an independent contractor. The court considered the fact that the claim forms for the services at issue stated that they were provided by an independent contractor. The court also considered previous decisions that held that once litigation has commenced, a statement in a claim form that the services were provided by an independent contractor may not be corrected, even if the statement was erroneous. The holding of the court was that the defendant has conclusively demonstrated that the plaintiff is not the provider entitled to the payment of the assigned first-party no-fault benefits, and therefore the defendant's motion to dismiss for failure to state a cause of action should have been granted.

The court considered the timely request for additional verification of a claim, the lack of response by the plaintiff, and timely denial of two claims for medical services by the defendant. The main issue decided was whether the defendant had established its entitlement to summary judgment and whether the plaintiff had failed to comply with discovery demands. The holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint was granted and the plaintiff's motion for summary judgment and cross motion for a protective order were denied. The Court also affirmed the denial of defendant's motion to dismiss the complaint based upon plaintiff's failure to comply with discovery demands.