No-Fault Case Law

The relevant facts considered by the court were whether an automobile collision was covered by the plaintiff's insurance policy and whether the injuries purportedly sustained due to the collision were a result of an insurance fraud scheme. The main issue decided was whether the defendant, in order to prove lack of coverage for the alleged injuries, needed to prove, by clear and convincing evidence, that the injuries were a result of an insurance fraud scheme or that the collision was not a covered accident. The court held that in order to prove lack of coverage, the defendant needed to establish, by a preponderance of the evidence, that the collision was not an accident and was instead a deliberate intentional occurrence, regardless of whether it was part of an insurance fraud scheme, and that the coverage was not required to be established by clear and convincing evidence. The court found that the defendant met its burden and the judgment was affirmed.

The relevant facts of this case involved an action by a provider to recover assigned first-party no-fault benefits. The Civil Court granted the provider's motion for summary judgment and implicitly denied the insurer's cross motion for summary judgment. On appeal, the Appellate Term affirmed the judgment, finding that the provider's affidavit and documents established evidence in admissible form and that any deficiency regarding proof of mailing of the claim forms was cured by the insurer's affidavit. The main issues decided in this case were whether the insurer's follow-up requests for verification were premature and without effect, and whether the insurer was precluded from raising certain defenses due to untimely denials of the provider's claims. The court held that the follow-up requests were premature and without effect, and that the insurer was precluded from raising most defenses due to the untimely denials. Additionally, the insurer's submissions were found to be insufficient to demonstrate that the defense of lack of coverage was valid.

The court considered the issue of whether the defendant insurance company was in compliance with regulations regarding the timing of follow-up requests for verification of claims submitted by a chiropractic provider. The main issues decided in this case were whether the plaintiff had made out a prima facie case to recover first-party no-fault benefits and whether the defendant's follow-up requests for verification were timely. The holding of this case was that the plaintiff had provided sufficient evidence to establish a prima facie case, and the defendant's follow-up requests for verification of claims were premature and without effect, as they were issued before the 30-day period had lapsed, therefore the judgment of the lower court was affirmed.

The court considered the issue of whether a follow-up request for verification of a no-fault benefits claim was issued prematurely, which would preclude the insurance company from raising certain defenses. The main issue decided in the case was whether the insurance company's premature follow-up request for verification affected its ability to deny the provider's claim on the basis of lack of medical necessity. The holding was that the insurance company's premature follow-up request for verification was without effect, and as a result, the 30-day claim determination period was not tolled. The insurance company was therefore precluded from raising certain defenses, including lack of medical necessity, and its failure to timely deny the provider's claim meant that there was no triable issue of fact. The judgment in favor of the provider was affirmed.

The court considered a motion by the defendant to dismiss the complaint due to the plaintiff's allegedly insufficient response to defendant's interrogatories. While the motion was pending, the defendant served the plaintiff with a notice to take the deposition of plaintiff's owner, Perumunda K. Sharma. The Civil Court denied defendant's motion and stated that the defendant did not establish its need for a deposition of Sharma. The court also noted that the plaintiff's purported cross motion, seeking a protective order with respect to the deposition of Sharma, was denied as moot. The main issue was whether the defendant had the entitlement to depose Sharma, and the holding of the case was that the portion of the order which provided that defendant did not establish its entitlement to depose Sharma is not appealable as of right, and the appeal was dismissed.

The court considered a motion by the defendant seeking to vacate a default judgment and compel the plaintiff to accept its late answer in an action to recover assigned first-party no-fault benefits. The main issues decided were whether the defendant had a reasonable excuse for its default and whether it had a potentially meritorious defense to the action. The holding was that the defendant demonstrated a reasonable excuse for its relatively short delay in answering the complaint, and made a prima facie showing of a potentially meritorious defense. Therefore, the branches of the defendant's motion seeking to vacate the default judgment and to compel the plaintiff to accept its late answer were granted. The court did not support the imposition of sanctions against the plaintiff, so the Civil Court's denial of the branch of defendant's motion seeking sanctions was left undisturbed.

The relevant facts considered by the court in this case included a provider's attempt to recover assigned first-party no-fault benefits and a cross motion by the defendant seeking to amend its answer to add affirmative defenses and to compel the plaintiff to respond to amended discovery demands. The main issue decided by the court was whether the Civil Court properly granted the defendant's cross motion, which sought to assert the affirmative defenses that the plaintiff was a fraudulently incorporated professional service corporation and lacked standing to bring the action, as well as to compel the plaintiff to respond to the amended discovery demands. The holding of the court was that the Civil Court did not improperly exercise its discretion in granting the defendant leave to amend its answer and to compel the plaintiff to respond to the amended discovery demands, as the proposed affirmative defenses were not devoid of merit and the amended discovery demands were material and necessary to the defendant's defenses.

The relevant facts considered by the court were that Liberty Medical Group, P.C. entered into a stipulation to settle a first party no-fault benefits action with New York Central Mutual Fire Insurance Company in 2002. The main issue decided was whether the stipulation was enforceable, as the defendant sought to vacate it, claiming it was based on fraud. The holding of the court was that the defendant failed to provide any competent evidence to support their claim that the stipulation was unenforceable, and that stipulations of settlement are favored by the courts and not lightly set aside. The court also noted that the defendant had failed to demonstrate any basis to excuse it from complying with the terms to which it had assented, and may not avoid its enforceability by claiming that the plaintiff's claims were the product of fraud. Therefore, the motion to vacate the stipulation was denied, and the decision of the court was affirmed.

The relevant facts considered by the court were that Bronx Expert Radiology, P.C. was suing New York Central Mutual Fire Insurance Company in order to recover first party no-fault benefits. The main issue decided was whether or not the defendant's medical expert should have been permitted to testify, as the expert's opinion may have been partly based on the review of medical records prepared by the plaintiff or other physicians. The holding of the court was that the defendant's medical expert should have been permitted to testify, as his testimony on lack of medical necessity would be limited to the basis for denial set forth in the original peer review report, and his opinion may have been based, at least in part, on his review of medical records related to the treatment provided to the assignor. The judgment was reversed, with $25 costs, and the matter was remanded for further proceedings.

The court considered the fact that Bronx Expert Radiology, P.C. submitted its claims for first party no-fault benefits to Great Northern Insurance Co. in March 2004, even though the health services were rendered in November 2003. Defendant denied the claims as untimely and requested plaintiff to provide a "clear and reasonable justification" for the delay, as required by the statute. The main issue decided was whether plaintiff had a reasonable justification for its delay in submitting the claims to defendant. The court held that plaintiff failed to meet its burden of establishing a reasonable justification for the untimely submission of its claims, as its proof was insufficient to justify the delay. The court also ruled that there is no requirement in the No-Fault statute or regulations imposing the need to show prejudice for untimely claims. Therefore, the appellate term reversed the trial court's decision and dismissed the complaint.