No-Fault Case Law

The New York University-Hospital for Joint Diseases brought a lawsuit against Esurance Insurance Company to recover no-fault medical payments for a patient who was in a car accident and was assigned to the hospital. NYU-Hospital argued that Esurance's denial of the claim was untimely, factual insufficient and of no merit as a matter of law. The court acknowledged that the hospital had proof the bill was mailed and received and that the payments were overdue, but found that Esurance raised a triable issue of fact as to whether the denial of the claim was timely and whether the patient was intoxicated at the time of the accident. Therefore, the Supreme Court affirmed the denial of the hospital's motion for summary judgment on the complaint.

The relevant facts considered in this case were that the defendant, Utica Mutual Insurance Company, had denied the plaintiff's claim for first-party no-fault benefits based on the assignor's failure to attend independent medical examinations (IMEs) scheduled by Hudson Valley Medical Consultants (HVMC). The defendant submitted affidavits from an employee of HVMC and the office manager of the psychologist who was to perform the IMEs, which established that the IME requests had been timely mailed and that the plaintiff's assignor had failed to appear for the scheduled IMEs. The main issue decided was whether the defendant had properly denied the plaintiff's claim based on the assignor's failure to satisfy a condition precedent to coverage. The court held that since the assignor's appearance at an IME is a condition precedent to the insurer's liability on the policy, the defendant was not precluded from raising the issue and properly denied the claim, affirming the Civil Court's order granting defendant's motion for summary judgment dismissing the complaint.

The main issue in this case was whether the defendant, Commerce Insurance Company, was entitled to summary judgment dismissing the complaint on the grounds of fraudulent procurement of the insurance policy due to the assignor misrepresenting his state of residence. The court ultimately held that the defendant was not precluded from raising its defense of fraudulent procurement of the insurance policy, as the affidavits submitted by the defendant's claims adjuster established that the assignor had indeed misrepresented his state of residence, making him ineligible to receive first-party no-fault benefits under the insurance policy in question. The court therefore reversed the judgment, vacated the order denying the defendant's motion for summary judgment, granted the defendant's motion for summary judgment dismissing the complaint, and denied the plaintiff's cross motion for summary judgment.

The court considered the facts of a case in which LDE Medical Services, P.C. sued Interboro Insurance Company to recover assigned first-party no-fault benefits. Plaintiff moved for summary judgment, and the defendant cross-moved for summary judgment dismissing the complaint. In support of its cross-motion, the defendant argued that it had timely denied the plaintiff's claims on the ground that the assignor had failed to attend independent medical examinations (IMEs) and that the plaintiff's motion for summary judgment was premature. The court found that the appearance at an IME is required whether the insurance company demands the IME before the claim form is submitted or after and that the defendant failed to establish that the assignor had failed to appear at the IMEs. The judgment was affirmed by the court because the defendant failed to show that discovery was needed to establish the existence of a triable issue of fact, and therefore, the plaintiff's motion for summary judgment was properly granted.

The main issue in this case was whether the medical services rendered by the plaintiff were medically necessary, as all other elements of the case had been established and the defendant had timely denied the claim on the grounds of lack of medical necessity. At the nonjury trial, the defendant's attorney requested an adjournment to secure the appearance of its witness, but the Civil Court denied the application and issued a decision awarding judgment in the defendant's favor. The defendant appealed from this decision, arguing that the Civil Court should have granted the adjournment. The Appellate Term, Second Department found that the Civil Court did not improvidently exercise its discretion in declining to grant the adjournment and affirmed the judgment in favor of the defendant. Therefore, the holding of the case was that the judgment in favor of the defendant was affirmed.

The plaintiff, NYU Hospital for Joint Diseases, sought to recover no-fault benefits under an insurance contract from Country Wide Insurance Company. The plaintiff claimed that the defendant failed to pay overdue benefits as required under the insurance policy. The court found that the plaintiff established its entitlement to judgment as a matter of law by submitting the necessary billing forms and other documentation. In response, the defendant failed to raise a factual issue as to whether it timely and effectively denied the plaintiff's claim. The court held that the defendant's denial of the claim was fatally defective, and therefore, the defendant's cross motion for summary judgment dismissing the complaint was denied. In conclusion, the judgment in favor of the plaintiff and against the defendant was affirmed.

The main issue in the case was whether the plaintiff, Yklik, Inc., as the assignee of Horacio Bello, was entitled to summary judgment in an action to recover assigned first-party no-fault benefits from GEICO Ins. Co. The court considered the evidence presented by both parties, including whether the defendant had failed to pay or deny the claim within the required 30-day period as stipulated by Insurance Law § 5106 (a). The court ultimately held that the plaintiff had failed to establish its prima facie entitlement to judgment as a matter of law, as it did not demonstrate that the defendant had failed to either pay or deny the claim within the requisite time period. Therefore, the order granting the plaintiff's motion for summary judgment was vacated, and the plaintiff's motion was denied. The dissenting opinion argued that the plaintiff had made a prima facie showing of its entitlement to summary judgment, as it had submitted evidence that the medical supplies had been provided to the assignor, and that the prescribed statutory billing forms had been mailed and received by the defendant insurer and remained unpaid. The dissenting opinion voted to affirm the judgment in favor of the plaintiff.

The court considered two unrelated claims for first party no-fault benefits, in which Allstate Insurance Company was the no-fault carrier for both claims. Lenox Hill Hospital sought payment for treatment provided to Eduardo Marrero and Mount Sinai Hospital sought payment for treatment provided to Gregory Bar. The main issue decided was whether the necessary billing forms and documents had been mailed to and received by Allstate and whether payment was overdue. The court held that the hospitals failed to establish a prima facie entitlement to judgment as a matter of law because they did not submit proof in admissible form sufficient to establish that the necessary billing documents were business records. Additionally, Allstate's defenses of timely denial and failure to respond to verification requests were not proven with sufficient evidence in admissible form, but the denial of the hospitals' claims was upheld.

The relevant facts considered by the court in this case were an action brought by Westchester Medical Center and New York Hospital Medical Center of Queens to recover no-fault benefits under a contract of insurance. New York Hospital Medical Center of Queens sought summary judgment on the second cause of action, and Westchester Medical Center appealed the denial of the motion. The main issue decided by the court was whether the plaintiff, New York Hospital Medical Center of Queens, as an assignee of Merna Ishak, was entitled to judgment as a matter of law on the second cause of action. The holding of the court was that while the plaintiff had demonstrated its entitlement to judgment based on the overdue payment of no-fault benefits, the defendant raised a triable issue of fact as to whether the plaintiff fully complied with the defendant's demand for verification. Therefore, the Supreme Court properly denied the plaintiff's motion for summary judgment on the second cause of action.

The relevant facts considered by the court were that the defendant was appealing an order from the Civil Court that denied its motion for summary judgment dismissing the complaint in an action to recover first-party no-fault medical benefits. The main issue decided by the court was whether the defendant had established prima facie that the notices of the independent medical examinations (IMEs) were properly mailed to the assignor and that he failed to appear for the IMEs. The court held that the defendant's motion for summary judgment was properly denied because it failed to meet its burden of establishing that the notices of the IMEs were properly mailed and that the assignor failed to appear, as required by law. Therefore, the denial of the defendant's motion was required regardless of the sufficiency of the plaintiff's opposition papers.