No-Fault Case Law
Advanced Recovery Equip. & Supplies, LLC v Tri-State Consumer Ins. Co. (2023 NY Slip Op 51239(U))
October 5, 2023
The provider's petition to vacate the master arbitrator's award was granted because the award lacked a rational basis. The Appellate Term, Second Department, affirmed the judgment granting relief under CPLR 7511 and remitting the matter for a new determination, relying on Matter of Acuhealth Acupuncture, P.C. v Country-Wide Ins. Co.; the award had upheld an arbitrator's denial of assigned no-fault benefits.
Vitaliti v New York City Tr. Auth. (2023 NY Slip Op 51156(U))
September 29, 2023
A master arbitrator's reversal for substantive legal error must be upheld unless irrational, even if legally incorrect. The hearing arbitrator awarded benefits after precluding the self-insurer's late evidence that its bus was not involved in the accident. The master arbitrator vacated the award and directed a new hearing, citing preclusion of the defense and disparate treatment of late submissions. The Supreme Court, Kings County, denied the injured claimant's petition under CPLR 7511 (b) (1) (iii). The master arbitrator had neither reweighed credibility nor reconsidered factual findings, and the decision was not arbitrary, capricious, or irrational. The court found it unnecessary to resolve whether the defense was precludable to decide the petition.
Westchester Radiology & Imaging, P.C. v MVAIC (2023 NY Slip Op 51516(U))
September 26, 2023
The provider's claim against MVAIC was premature because exhaustion of remedies arising from the collision with a USPS vehicle was unproven. The injured claimant was a bicyclist, and the offending vehicle's owner and operator were known. Under Insurance Law § 5201 and Insurance Law § 5221, MVAIC remained a remedy of last resort. Unavailability of no-fault benefits from the United States did not excuse exhaustion: an administrative claim and, after denial, a tort action were available under 28 USC § 2675. The record did not establish use of that process or denial by USPS or the appropriate agency. The Civil Court, Bronx County, granted MVAIC summary judgment, denied the provider's cross motion, and dismissed without prejudice.
Absolute Med. Supplies, Inc. v Unitrin Advantage Ins. Co. (2023 NY Slip Op 51237(U))
September 22, 2023
The insurer's summary judgment motion based on claim submission more than 45 days after service was denied on appeal. The Appellate Term, Second Department, modified the order to deny the insurer's motion and affirmed denial of the provider's cross motion. The insurer showed untimely submission prima facie, but the provider's opposing affidavit raised a triable issue, following Longevity Med. Supply, Inc. v MVAIC.
Heaven & Earth Acupuncture, P.C. v Hartford Ins. Co. of Ill. (2023 NY Slip Op 51236(U))
September 22, 2023
An insurer seeking summary judgment on policy exhaustion must prove payment of the policy limits under 11 NYCRR 65-3.15. The Appellate Term, Second Department, modified the order to deny the insurer's motion and affirmed denial of the provider's cross motion. The insurer's claim specialist relied on a payment log that was not annexed to the moving papers, so the insurer failed to establish any payments under the policy and did not make a prima facie showing of exhaustion. The provider's affidavit failed to establish either that the claims had not been timely denied or that timely denials were conclusory, vague, or without merit as a matter of law.
Parisien v Esurance (2023 NY Slip Op 51235(U))
September 22, 2023
The insurer's founded belief that the collision was staged did not establish its coverage defense through sufficient admissible evidence. The investigator relied on records, photographs, and EUO transcripts, but the insurer failed to establish noncoverage as a matter of law under Central Gen. Hosp. v Chubb Group of Ins. Cos. The provider likewise failed to establish its prima facie entitlement to summary judgment by showing untimely denials or denials that were conclusory, vague, or legally meritless. The Appellate Term, Second Department, modified the order to deny the insurer's cross motion and affirmed the denial of the provider's motion. It did not address misrepresentation in policy procurement because the insurer had not sought dismissal on that ground.
Jiang Acupuncture PC v State Farm Ins. Co. (2023 NY Slip Op 50961(U))
September 11, 2023
The insurer failed to prove good cause for licensing verification with admissible evidence supporting summary judgment. The Civil Court, Queens County, denied dismissal based on failure to supply verification within 120 days under 11 NYCRR 65-3.8 (b) (3). The insurer relied on an unsigned EUO transcript without showing submission to the witness for signature under CPLR 3116 (a); the investigator's account of that testimony was hearsay. The provider's cross motion was also denied under CPLR 3212 (f) because outstanding financial and corporate records within its exclusive control raised factual issues concerning licensing eligibility under 11 NYCRR 65-3.16 (a) (12). Although the denials established receipt and overdue payment, the eligibility defense was not precluded by untimely denial.
American Tr. Ins. Co. v Nexray Med. Imaging PC (2023 NY Slip Op 50953(U))
September 8, 2023
The insurer's petition to vacate a master arbitration award was denied because it submitted an award from a different arbitration. The Supreme Court, Kings County, applied prima facie evidentiary requirements comparable to CPLR 3212 (b) in the CPLR article 75 proceeding. Without the correct award, it could not assess the alleged errors. It granted the provider's cross-petition and confirmed the award. Under 11 NYCRR 65-4.10 (j) (4), it awarded a nominal litigation attorney's fee because counsel overlooked the defect and supplied no supporting fee evidence. Interest under Insurance Law § 5106 (a) and 11 NYCRR 65-3.9 (c) was tolled between denial and arbitration because arbitration was not requested within 30 days.
American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U))
September 1, 2023
A provider's substantial compliance with reasonable additional verification requests does not make its claims payable. The insurer sought article 75 review of a master arbitration award affirming payment of eight chiropractic bills. The Supreme Court, Kings County, found five claims premature because requested sign-in sheets and livery-fund information remained outstanding under 11 NYCRR 65-3.5 (c) and 65-3.8 (a) (1). Medical documentation and the assignor's EUO testimony did not excuse compliance. The provider prevailed on medical necessity for two bills: treatment notes could overcome the IME report without a formal rebuttal. Nevertheless, because partial confirmation and vacatur were unavailable, the court granted vacatur under CPLR 7511 (b) (1) (iii) and remanded the entire claim for rehearing under CPLR 7511 (d).
American Tr. Ins. Co. v Rutland Med., PC (2023 NY Slip Op 50814(U))
August 4, 2023
A no-fault arbitrator need not require a formal rebuttal specifically addressing an insurer's peer review or IME report. The Supreme Court, Kings County, denied the insurer's vacatur petition and granted the provider's cross-petition to confirm. Following American Tr. Ins. Co. v Right Choice Supply, it held that summary judgment rebuttal requirements do not govern no-fault arbitration; medical necessity and evidentiary weight remain within the arbitrator's discretion under 11 NYCRR 65-4.10 (a) (4). The arbitrator found the peer reviews insufficient and the IME rebutted by clinical examination findings. Although the master arbitrator omitted the asserted legal issue, the affirmance was rational and resolved the parties' rights and obligations, so no ground for vacatur under CPLR 7511 (b) (1) was established.