No-Fault Case Law

The court considered whether the insured decedent's injuries were caused by an accident within the meaning of the uninsured motorist endorsement and other provisions of the insured's policy. The main issue was whether the coverage of the policy was applicable to injuries caused by the intentional conduct of the operator of the vehicle. The holding of the court was that, viewed from the insured's perspective, the occurrence was an unexpected or unintended event and therefore an "accident" within the meaning of the policy, entitling the insured to benefits under the uninsured/underinsured motorist endorsement, mandatory personal injury protection endorsement, and death, dismemberment, and loss of sight endorsement of the policy. The court also held that the insured was entitled to coverage under the personal injury protection and death, dismemberment, and loss of sight endorsements of the policy.

The main issue in this case was whether or not the court should grant a permanent stay of arbitration following the denial of a claim for no-fault insurance benefits by the insurance company. The court considered whether the denial of benefits is a dispute involving the insurer's liability to pay first party benefits. The holding of the court was that the Supreme Court properly refused to grant a permanent stay of arbitration, and that the issue of whether the offset for workers' compensation benefits exceeds the monthly limit of first party benefits is a matter for arbitration. The court also rejected the petitioner's contention that it was denied its right to seek a loss-transfer claim from additional proposed respondents.

The court considered the fact that the petitioner (an insurance company) appealed from an order of the Civil Court which denied its petition to vacate an arbitration award in favor of the respondent, awarding him unpaid no-fault benefits in the principal sum of $11,170.42, and granted respondent's cross petition to confirm the arbitration award. The main issues were whether the $50,000 limit of the subject insurance policy was exhausted before the petitioner-insurer was obligated to pay respondent's claim, and whether the arbitrator's award directing payment in excess of the $50,000 limit of a no-fault insurance policy exceeds the arbitrator's power and constitutes grounds for vacatur of the award. The holding of the court was to reverse the order denying the petition to vacate the arbitration award, and remand the matter to Civil Court for a framed issue hearing regarding whether the $50,000 limit of the subject insurance policy was exhausted before the petitioner-insurer was obligated to pay respondent's claim.

The Court considered a case in which a hospital was seeking to recover no-fault medical benefits from an insurance company after being awarded a judgment in its favor. The defendant, an insurance company, sought to modify the judgment, claiming it exceeded the coverage limit of the policy due to payments previously made to other healthcare providers. The main issue was whether the defendant was entitled to modify the judgment under CPLR 5015(a). The holding of the case was that the defendant's motion to modify the judgment was properly denied by the Supreme Court. The defendant failed to specify on which grounds its motion was based, and it did not establish its entitlement to relief on any of the enumerated grounds. Furthermore, the court found that modification of the judgment in the interest of justice was not warranted.

The court considered the fact that the defendant had timely mailed its request and follow-up request for verification to the plaintiff, in accordance with the defendant's standard office practices and procedures. The plaintiff's medical biller had denied receipt of the verification requests, but the court found that this did not overcome the presumption that proper mailing had occurred. Since the plaintiff did not serve responses to the verification requests prior to the commencement of the action, the defendant's motion for summary judgment dismissing the complaint was properly granted. The main issue decided was whether the plaintiff's action for recovery of assigned first-party no-fault benefits was premature due to failure to provide requested verification of the claim. The holding of the court was that the judgment granting the defendant's motion for summary judgment was affirmed.

The parties in this case were the Unitrin Advantage Insurance Company and Bayshore Physical Therapy, PLLC. The court decided whether the insurance company could retroactively deny no-fault insurance claims on the basis of the assignors' failure to appear for independent medical examinations (IMEs). The court ruled that the insurance company can retroactively deny claims for failure to appear for IMEs, even if the initial denials were based on lack of medical necessity. Additionally, it was decided that a denial based on the breach of a condition precedent to coverage voids the policy from the beginning. The court also addressed that insurers can request IMEs in accordance with the procedures and timeframes set forth in the no-fault implementing regulations and if the assignors did not appear, the denial of claims is valid. Finally, the court found that the argument that all IMEs must be conducted by physicians was unavailing.

The appellant, GEICO Insurance Company, appealed from a judgment entered in favor of the respondent, Alur Medical Supply, Inc., as the assignee of Gladys Ferrer. The judgment was based on an order by the Civil Court of New York granting the respondent's motion for summary judgment and denying the appellant's cross motion for summary judgment. This case concerned the failure of the appellant's claims examiner to explain handwritten additions to the denial of claim forms. The relevant issues were whether the claim denial forms were timely filed and whether there was a lack of medical necessity for the equipment at issue. The court held that the appellant's claim denial forms were timely filed and that there was a lack of medical necessity for the equipment, shifting the burden to the respondent to rebut this showing, which it failed to do. Therefore, the judgment in favor of the respondent was reversed, and the respondent's motion for summary judgment was denied.

The relevant facts considered by the court were that the Civil Court had awarded the plaintiff $10,196 in no-fault benefits, as well as attorney's fees, and the defendant rejected the proposed judgment and submitted their own calculation for the attorney's fees. The main issue decided was the proper method for calculating attorney's fees in no-fault actions, based on the aggregate of all bills submitted by the provider with respect to each insured, up to a maximum of $850, as determined by the Court of Appeals in LMK Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co. The holding of the case was that the clerk's mistake in entering a judgment including attorney's fees in the sum of $4,259.42 was subject to correction by the Civil Court, and the matter was remitted for the entry of a corrected judgment awarding plaintiff attorney's fees in the sum of $850.

The relevant facts the court considered were that the defendant in this action to recover assigned first-party no-fault benefits breached an agreement by serving the cross-motion and opposition after the extended due date. The main issue before the court was whether the defendant could move for leave to renew its adversary's motion on the basis that its cross-motion and opposition, which was rejected and not entertained, constitutes new facts. The holding of the court was that the defendant's untimely responsive papers, once rejected, constituted a default on the part of the defendant in opposing plaintiff's motion. Even if a motion for leave to renew was appropriate, the defendant failed to meet the criteria for relief under either theory. Therefore, the defendant's motion was denied.

The court considered the fact that plaintiff, a professional corporation, sought to recover first-party, no fault benefits for services rendered to its assignor who was injured in an automobile accident in 2002. It also considered the numerous claims submitted by the plaintiff and the subsequent judgment and stay on entry and execution of that judgment due to miscalculated interest. The main issue decided was whether the plaintiff was entitled to its requested interest and whether defendant's motion to vacate or modify the judgment and stay enforcement should be granted. The holding of the case was that the motion to vacate or modify the judgment was denied, but the motion for an order staying enforcement was granted. The court also determined that the plaintiff was not entitled to compound interest and that the interest had been tolled as of a certain date due to plaintiff's unreasonable delay in entering the judgment.