No-Fault Case Law

The central facts of the case are that plaintiff insurance company, Progressive, initiated a declaratory judgment action against defendant Michelle Strough, arguing that Strough failed to cooperate with Progressive as required by her insurance policy after being injured in a motor vehicle accident. Progressive claimed that because of Strough's failure to cooperate, the company had no duty to indemnify her or to pay her no-fault insurance benefits. The main issues in this case were whether the doctrine of res judicata applied to the final arbitration award, and whether plaintiff had provided evidence to prove that Strough failed to cooperate. The Appellate Division held that the judgment issued by the Supreme Court, denying Strough's motion for summary judgment and confirming the award of the master arbitrator, was correctly affirmed. The court concluded that the action was not barred by res judicata and that Progressive had the right, under Insurance Law § 5106 (c) and 11 NYCRR 65-4.10 (h) (1) (ii), to a de novo determination of the dispute. The appellate court also determined that Progressive failed to support its motion with evidence provided by an individual with personal knowledge of the facts and therefore failed to establish its entitlement to judgment as a matter of law. Therefore, the portion of Progressive's cross-motion for summary judgment was properly denied.

The relevant facts considered in this case included the denial of no-fault benefits to Dr. Mills by Government Employees Insurance Co. (GEICO) after a motor vehicle accident and subsequent injuries. Dr. Mills petitioned the court for a trial, de novo, to challenge the decision of an Arbitrator that upheld the denial of benefits. The main issue decided by the court was whether Dr. Mills was entitled to further no-fault benefits, based on his claim of lost earnings due to his injuries. The court ultimately held that the arbitration process afforded Dr. Mills due process, and the decisions of the Arbitrator and Master Arbitrator had a sound basis in the record and were not irrational, capricious, or an abuse of discretion. Therefore, the arbitration award was affirmed, and GEICO was directed to settle judgment. The court also found that Dr. Mills was not entitled to a trial de novo and that a demand for relief under Article 75 was untimely.

The relevant facts the court considered were that the defendant insurance company issued denial of claim forms in April and May of 2001, which partially denied payment on the grounds that no fee schedule existed for the treatment provided and that payment could thus be limited to a reasonable and customary fee. The main issue decided was whether the denials of claim by the defendant's insurance company were issued on prescribed forms and whether the defendant's entitlement to summary judgment dismissing the complaint was properly submitted. The holding of the court was that the plaintiff failed to establish prima facie entitlement to judgment as a matter of law and that the defendant made a prima facie showing of its entitlement to summary judgment dismissing the complaint. Additionally, the plaintiff's contention that the defendant failed to offer sufficient evidence in support of the "similar procedure" for comparison to the services offered was not properly before the Court.

The case is about a dispute between Chubb Insurance Company and GEICO Insurance Company and STATEWIDE INSURANCE COMPANY regarding an inter-company arbitration demand after a three-vehicle accident in which Chubb paid benefits to Chenille Bonner, a New York City Transit Authority bus driver. Chubb filed for reimbursement of these benefits to GEICO and Statewide Insurance Company, with the case being submitted to arbitration. The arbitrator initially awarded Chubb a total of $42,065.56, but GEICO argued that the arbitrator had incorrectly applied New York regulations and the amended award reduced Chubb's recovery to $21,032.78. After Chubb filed a petition to vacate the amended award and reinstate the original award, the Supreme Court granted the petition but also addressed the merits. GEICO later filed a motion to vacate the default judgment, claiming that it never received any notice of the proceeding until after the entry of judgment. However, the court denied this motion and upheld its earlier decision.

The main issues decided in this case were whether the trial court properly vacated the notice of trial and directed the plaintiff to respond to the defendant's discovery demands and appear for an examination before trial with respect to the defense based on the plaintiff's alleged fraudulent incorporation. The court considered the fact that the plaintiff had represented that discovery was complete, but the defendant argued that it was not. The court also considered whether the defendant was entitled to conduct an examination before trial of the plaintiff. The holding of the case was that the trial court's decision to vacate the notice of trial and certificate of readiness and direct the plaintiff to respond to the defendant's discovery demands and appear for an examination before trial was affirmed, and the defendant was entitled to conduct the examination before trial.

The court considered the case of Post Traumatic Medical Care, P.C. v Progressive Casualty Insurance Company, which involved a provider seeking to recover first-party no-fault benefits. The main issue decided was whether the plaintiff was entitled to summary judgment, as the defendant argued that the assignors breached the cooperation clause of the insurance policy by failing to attend scheduled independent medical examinations (IMEs). The court found that the defendant failed to create a triable issue of fact by competent proof that the assignors failed to attend the IMEs, as they did not submit evidence in admissible form from anyone with personal knowledge of the nonappearances. Therefore, the order was reversed, and plaintiff's motion for summary judgment was granted, with the matter remanded for the calculation of statutory interest and attorney's fees.

The court considered a case in which A Plus Medical, acting as the assignee of Sheresse O'Neill, sued Government Employees Insurance Co. for no-fault benefits in the amount of $878.67 for medical services provided. Plaintiff and defendant agreed that the only issue for trial was the medical necessity of the services, based on a peer review. The burden was on the defendant to prove lack of medical necessity, and they called a witness, Dr. Drew Stein, to testify that an MRI of the right shoulder was not medically necessary. However, the court found that Dr. Stein's testimony was insufficient to establish a defense based on the lack of medical necessity. The court held that the evidence was insufficient to sustain the defendant's burden and ruled in favor of the plaintiff for the amount of $878.67, plus statutory interest and attorneys' fees.

The relevant facts considered by the court in the case of Bronx Multi Med. Care, P.C. v Kemper Cas. Ins. Co. included the plaintiff's motion for summary judgment to recover first party no-fault benefits, which was denied by the Civil Court of the City of New York. The main issue decided was whether the plaintiff made a prima facie showing of entitlement to summary judgment, and whether the defendant raised triable issues of fact in opposition. The holding of the court was that the order denying the plaintiff's motion for summary judgment was reversed, and the plaintiff's motion was granted in the principal sum of $8,054.90. The court found that the plaintiff had submitted evidentiary proof that the prescribed statutory billing forms had been mailed and received, and that payment of no-fault benefits was overdue, while the defendant failed to raise triable issues of fact in opposition. Consequently, the plaintiff was entitled to summary judgment.

The main issues in this case were whether the defendant, State Farm Mutual Inc. Co., had the right to dismiss the plaintiff, Bay Plaza Chiropractic's complaint due to the plaintiff's failure to appear for an examination before trial or provide verified, complete, and meaningful responses to the defendant's discovery demands. The court also had to consider whether there was evidence to support the defendant's claim that the plaintiff was a fraudulently incorporated facility and therefore ineligible to collect non-fault benefits. The court ultimately held that the defendant had a "founded belief" that the plaintiff was actually controlled by a non-licensed professional, and therefore had made allegations sufficient to raise an issue of fact as to whether the plaintiff was fraudulently incorporated. As a result, the court directed the plaintiff to produce their purported owner, Dr. Geraldine McGowan, for an exam before trial within 30 days and comply with all discovery requests related to corporate structure and fraudulent incorporation. The court also ordered the plaintiff to respond to the applicable defendant's discovery requests within 45 days and to renotice Dr. McGowan for an EBT within 30 days after receiving plaintiff's responses. However, the court declined to dismiss the plaintiff's complaint, as they had responded to some of the discovery requests and had not engaged in willful, contumacious, or bad faith conduct.

The court considered the timing of interest accruing on first-party benefits and the validity of section 65-3.9 (c) of the Insurance Law. The main issue decided was whether section 65-3.9 (c) was contrary to Insurance Law § 5106 (a). The holding was that the regulation was not contrary to the statute's clear language and was a valid regulation within the scope of the superintendent's authority. The court concluded that the regulation was not unreasonable or contrary to the statute under which it was promulgated, and that it had a rational basis for providing a penalty against insurers who do not comply with the time frames of the No-Fault Law. Therefore, the petition was denied, and the cross-petition to confirm the arbitration award was granted.