No-Fault Case Law

The main issue of the case was whether the defendant, Nationwide Mutual Insurance Company, had properly disclaimed coverage under the supplemental uninsured/underinsured motorist (SUM) benefits of an automobile insurance policy issued to the plaintiff, Sukeerti Bhatt. Plaintiff had promptly notified defendant of a motor vehicle accident in which she was involved, as required by the policy, and filed a claim for no-fault benefits shortly thereafter. However, plaintiff did not notify defendant of her claim under the SUM endorsement until almost three years after the accident. The court considered the question of whether the defendant must establish that it was prejudiced by the late notice of the SUM claim in order to properly disclaim coverage. The court ultimately held that defendant had failed to establish that it was prejudiced by plaintiff's delay in providing notice of the SUM claim, and therefore affirmed the denial of defendant's motion for summary judgment dismissing the complaint.

The court considered that the plaintiff, a chiropractor, had submitted proof that the statutory billing forms had been mailed and received, and that payment of no-fault benefits was overdue. The main issue decided was whether the defendant, State Farm General Insurance Company, had timely denied the plaintiff's no-fault claims, and whether the defendant's defense of lack of medical necessity was admissible. The holding of the case was that the plaintiff was granted summary judgment in the principal sum of $554.76 because they had established a prima facie entitlement to summary judgment, and the defendant failed to raise a triable issue. The unsworn chiropractor's report submitted by the defendant in support of its defense of lack of medical necessity was not in admissible form, and was thus excluded from consideration.

The court considered the fact that the plaintiff's claim for no-fault benefits was submitted beyond the 45-day statutory period, but included correspondence attempting to explain the delay in filing. The main issue decided was whether the defendant, an insurance company, provided the claimant with the opportunity to submit a reasonable justification for the late notice and whether the defendant gave appropriate consideration to the situation where the claimant had difficulty ascertaining the insurer's identity. The court held that the denial of the defendant's motion for summary judgment was sustained because the record did not indicate whether the defendant gave any consideration to the plaintiff's explanation for its tardy submission as required by the regulations.

The relevant facts of the case involved the defendant, AIU Insurance Company, seeking summary judgment to have a policy retroactively cancelled and deemed void ab initio due to a material misrepresentation in the insurance application. The plaintiff, Li-elle Service Inc., opposed the motion, claiming that the policy obtained using fraudulent misrepresentations could not be void ab initio. The defendant alleged that the insured, Jorge Garcia, misrepresented his residency, which led to the policy being cancelled. The main issue decided by the court was whether the policy was void ab initio and if the defendant had met its burden of proof to obtain summary judgment. The court held that there was a conflict of law between Virginia and New York, and that Virginia law prevailed. It also determined that the defendant had not provided sufficient proof that it relied on the misrepresentations when it undertook the risk, and therefore denied the defendant's motion for summary judgment.

The relevant facts considered by the court in Uptodate Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. involved an action by a provider to recover assigned first-party no-fault benefits for services rendered. The plaintiff had sought to recover assigned first-party no-fault benefits for services rendered to a different assignor in a prior arbitration proceeding, but the arbitrator determined that the plaintiff was ineligible to receive reimbursement of no-fault benefits because it was a fraudulently incorporated professional service corporation. The main issue decided by the court was whether the defendant should have been granted leave to amend its answer in order to interpose the affirmative defense of collateral estoppel, and if the plaintiff had a full and fair opportunity to litigate the issue previously decided in the arbitration proceeding. The holding of the court was that the defendant should have been granted leave to amend its answer as the proposed affirmative defense was neither devoid of merit nor palpably insufficient as a matter of law, and the defendant established that the issue previously decided by the arbitrator was identical to the issue in the present action. Therefore, the court granted the defendant's cross motion for summary judgment and dismissed the complaint.

The relevant facts considered by the court were that plaintiff, Vista Surgical Supplies, Inc., had moved for summary judgment to recover assigned first-party no-fault benefits, and defendant, GEICO Insurance Company, cross-moved for summary judgment, asserting that the supplies provided were not medically necessary based on a peer review report. The main issue was whether the supplies provided were medically necessary, and the court had to decide whether the denial of claim form submitted by defendant was defective and whether the peer review report established lack of medical necessity. The holding of the case was that the denial of claim form submitted by the defendant was not defective, and defendant established lack of medical necessity based on the peer review report, with plaintiff failing to provide evidence in opposition to show that the supplies provided were medically necessary. As a result, the court affirmed the order granting defendant's cross motion for summary judgment dismissing the complaint.

The relevant facts the court considered in the case of Dilon Med. Supply Corp. v Travelers Ins. Co. were that the plaintiff had proved its prima facie case for first-party no-fault benefits, and the sole issue at trial was the medical necessity of the supplies provided to the assignor. Defendant's expert medical witness testified that the durable goods provided were not medically necessary. The main issue decided was whether the supplies provided were medically necessary, and the holding of the court was that the trial court's determination in favor of the defendant was based on a fair interpretation of the evidence, as plaintiff failed to offer any rebuttal evidence to show that the supplies were medically necessary. Therefore, the judgment dismissing the complaint was affirmed.

The relevant facts the court considered were that the defendant moved for summary judgment dismissing the complaint on the grounds that their insured and insured's vehicle were not involved in the hit-and-run accident that the plaintiff was seeking no-fault benefits for. The defendant presented affidavits from their insured and their insured's wife stating that they lived in a different city and had not been in Brooklyn in over 30 years. The plaintiff only provided an affirmation from their attorney arguing that the defendant's papers did not make a prima facie showing entitling them to summary judgment. The main issue decided was whether the defendant made a prima facie showing that their insured's vehicle was not involved in the hit-and-run accident, and if the plaintiff presented sufficient facts to demonstrate a triable issue of fact to defeat the motion for summary judgment. The holding of the case was that the defendant did make a prima facie showing that their insured's vehicle was not involved in the accident, and the plaintiff failed to present sufficient facts to demonstrate a triable issue of fact, so the Civil Court properly granted the defendant's motion for summary judgment dismissing the complaint.

The main issue of the case was whether the denial of the claim based on lack of medical necessity was timely, and if the denial was based on a legitimate peer review report. The court found that the denial of plaintiff's claim was timely, and that the peer review report submitted by the defendant was sufficient to establish a triable issue of fact as to the medical necessity of the supplies in question. The court reversed the judgment, vacated the order granting the plaintiff's motion for summary judgment, and denied the motion for summary judgment, holding that the denial of the claim was timely and that there was sufficient evidence to show a triable issue of fact. The court did not address the propriety of the Civil Court's determination with respect to the plaintiff's prima facie case.

The court considered that the defendant failed to establish that the statutory time period in which it had to pay or deny the plaintiff's claim was tolled, as its follow-up verification request was sent prior to the expiration of the 30-day period within which the requested verification had to be provided. The main issue decided was whether the defendant was precluded from asserting its defense of lack of medical necessity, and the holding was that the defendant failed to timely deny plaintiff's claim and is precluded from raising most defenses, including its proffered defense of lack of medical necessity. The judgment of the lower court granting the plaintiff's motion for summary judgment was affirmed.