No-Fault Case Law

The relevant facts the court considered were that the appellant was trying to recover first-party no-fault benefits from the respondent. The respondent moved for summary judgment to dismiss the complaint, which was granted, and denied the appellant's cross-motion for summary judgment. The issues decided was whether the denial of claim forms were mailed, and whether the appellant's assignor failed to appear for scheduled examinations. The holding of the case was that the respondent's motion for summary judgment was properly granted, and the appellant's cross motion was properly denied. The appearance of the appellant's assignor at an examination under oath was a condition precedent to the respondent insurer's liability. Therefore, the respondent's motion was properly granted and the appellant's cross motion was properly denied.

The court considered the defendant's motion for summary judgment dismissing the complaint in an action to recover assigned first-party no-fault benefits. The claims pertained to assignors Eridania Hiraldo, Manuel Espinal, and Milton Williams. The main issues decided were whether there was coverage for the claims made by Hiraldo and Espinal, and whether the denial of claim forms constituted evidence inadmissible form pursuant to the business records exception to the rule against hearsay. The court held that the denial of claim forms and the notice of cancellation offered by the defendant did not need to qualify as business records, as they were not being offered for a hearsay purpose. As a result, the order granting defendant's motion for summary judgment was affirmed.

The court considered a case where a provider was seeking to recover assigned first-party no-fault benefits. The main issue was whether, within one year of the accident, it was ascertainable that further expenses may be incurred as a result of the injury. The Civil Court concluded that further expenses were ascertainable because the injured party had submitted an application for no-fault benefits within two months of the accident. However, the court found that the stipulated facts did not cover all relevant points of dispute, specifically whether the injured party received any relevant treatment and incurred any relevant expenses within the one-year period following the accident. Therefore, the court reversed the judgment and remitted the matter to the Civil Court where the parties could stipulate to a more definite statement of facts or proceed to trial on the disputed issue in accordance with the decision.

The court considered that on September 1, 2007, Vitaly Polyakov was involved in a motorcycle accident and was injured. Polyakov reported to the police officer who responded to the scene that an unidentified vehicle struck his motorcycle. At the time of the accident, Mikhail Polyakov, Vitaly's father had a policy of automobile insurance. New York Central Mutual Fire Insurance Company denied the claim for supplementary uninsured/underinsured motorists benefits that Polyakov filed, on the grounds that the motorcycle he was riding at the time of the accident was not an insured vehicle under the subject policy. Polyakov demanded arbitration and the court held that the petition should have been granted, based on the policy language that was not ambiguous. The court found that the Sum endorsement under the subject policy specifically excluded coverage for injury to an insured while occupying a motor vehicle owned by that insured, if such motor vehicle is not insured for Sum coverage by the policy under which a claim is made.

The court in this case had to decide on a motion to reargue the court's decision regarding the timeliness of the defendant's denial of plaintiff's claim. Plaintiff Jesa Medical Supply, Inc. sought payment of first-party no-fault benefits from defendant American Transit Insurance Co. The court held that the defendant's denial was one day late, not two days late because Presidents' Day, a legal holiday, should have been excluded in computing the time needed for the verification request. According to 11 NYCRR 65-3.5 (b) and 11 NYCRR 65-3.8 (j), defendant's request for additional verification within 15 business days would exclude legal holidays from the calculation of the number of days required to submit the additional verification requests. Therefore, the motion to reargue was granted, and the case was set down for trial on the sole issue of medical necessity.

The court considered the defendant's motion for summary judgment dismissing the complaint, based on the fact that they had made a prima facie showing that two separate requests for an independent medical examination ("IME") of plaintiff's assignor were duly mailed to the assignor and that the assignor failed to appear for the examination. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint, and the court held that they were. The court noted that the defendant was not required to produce the applicable automobile insurance policy in order to establish that the mandatory personal injury endorsement included an IME provision. Therefore, the defendant's motion for summary judgment was granted and the complaint was dismissed.

The court considered the plaintiffs' motion for summary judgment on the complaint, which sought recovery of overdue assigned first-party no-fault benefits. The main issues decided were whether the plaintiffs were entitled to partial summary judgment on the issue of liability for recovery of these benefits, and whether plaintiff Carnegie Hill Orthopedic Services was entitled to judgment as a matter of law on overdue assigned first-party no-fault benefits. The court held that the plaintiffs were entitled to partial summary judgment on the issue of liability for the first cause of action, and plaintiff Carnegie Hill Orthopedic Services was entitled to judgment as a matter of law on the second and third causes of action seeking recovery of overdue assigned first-party no-fault benefits. The court ordered the matter to be remanded for apportionment between the plaintiffs of the damages on the first cause of action, as the plaintiffs had failed to establish such apportionment in their motion papers.

The court considered the motion brought by the plaintiff, a chiropractic medical provider, to recover assigned first-party no-fault benefits from the defendant insurance company. The plaintiff sought leave to enter a default judgment when the defendant failed to appear or answer the complaint. However, the motion was unopposed and was ultimately denied by the Civil Court. On appeal, the Appellate Term affirmed the denial of the motion, as the plaintiff's papers did not demonstrate a prima facie entitlement to judgment as a matter of law, as required by CPLR 3215 (f). The court also stated that the plaintiff was not entitled to alternative relief seeking a finding for all purposes in the action that it had established its prima facie case. The Appellate Term modified the order to provide that the plaintiff's motion was denied with leave to renew upon proper papers.

The court considered the facts that a provider (Triangle R, Inc.) had moved for summary judgment to recover assigned first-party no-fault benefits from GEICO Insurance Company. GEICO opposed the motion, stating that the action was premature because it was commenced before GEICO had received responses to its outstanding verification requests. The main issue decided was whether the action by the provider was premature due to GEICO not receiving the requested verification. The holding of the case was that GEICO's appeal was deemed to be from the judgment, and it was reversed without costs. The court vacated the order, denied the provider's motion for summary judgment, and granted GEICO's cross motion for summary judgment dismissing the complaint without prejudice to the provider's commencement of a new action.

The main issues in this case concerned a provider's attempt to recover first-party no-fault benefits from an insurance company, which had denied the claim on the basis that the treatments were not medically necessary. The court considered the sworn peer review report and the sworn independent medical examination report by the insurance company's chiropractors, which provided a factual basis and medical rationale for their determination that the treatments were not medically necessary. The court held that the insurance company's moving papers made a prima facie showing that they were entitled to judgment as a matter of law, shifting the burden to the provider to raise a triable issue of fact. The provider's affidavit in opposition to the insurance company's motion was found to be insufficient to raise a triable issue of fact, as it merely consisted of a conclusory statement by the affiant, the doctor who had provided the treatments, reaffirming his opinion that the disputed services were medically necessary. Therefore, the court reversed the lower court's decision, vacated the previous order, and granted the insurance company's motion for summary judgment while denying the provider's cross motion for summary judgment.