No-Fault Case Law

The case heard in December 10, 2007 as cited in 2007 NY Slip Op 27542, was a dispute between Odessa Medical Supply, Inc and Government Employees Insurance Company. The dispute was regarding $1,152 Odessa Medical Supply, Inc. claimed for health services rendered following a motor vehicle accident on October 28, 2004. Government Employees Insurance Company denied the claim on the grounds that the medical equipment for which the plaintiff submitted a bill was not medically necessary. At trial, the court issued an order in favor of Odessa Medical Supply, Inc based on the authority of Appellate Term, Second and Eleventh Judicial Districts. This was on the grounds that Medical necessity was not specified on the defendants denial of claim form. The defendant appealed the decision and the case was renewed after a change in law on November 3, 2006. Upon renewal, the court vacated the previous decision and the plaintiff's motion for preclusion and for a directed verdict were denied. The case was to be restored for a new trial as a result of a change in the existing law made by the Appellate Division. The main issue that was decided was whether the initial case's decision should be vacated due to a change in law. The holding of the case was that the defendant's motion for leave to renew was granted. Thus, upon renewal, the initial decision was vacated, and the plaintiff's motions in limine for preclusion and for a directed verdict were denied. The court ordered the action to be placed upon an appropriate calendar for trial and to notify the respective parties. The case was being restored to the trial calendar as a result of a change in existing law made by the Appellate Division.

The main issue in this case was whether the provider was entitled to recover assigned first-party no-fault benefits from the insurance company. The court considered the evidence presented, including an affirmation from the plaintiff's counsel, an affidavit by an employee of the plaintiff, and various documents annexed to the motion papers. The affidavit by the plaintiff's employee was deemed insufficient to establish their personal knowledge of the plaintiff's practices and procedures, thereby failing to lay a foundation for the admission of the documents as business records. As a result, the court denied the plaintiff's motion for summary judgment on the grounds that there were issues of fact as to coverage and the timeliness of the defendant's denial of claim forms. The holding of the court was to affirm the order denying the plaintiff's motion for summary judgment, albeit on different grounds.

The court considered a proceeding pursuant to CPLR article 75 to confirm two arbitration awards. Allstate Insurance Company appealed from a judgment in favor of the petitioner, Fireman's Fund Insurance Company, in the principal sum of $36,274.86. The main issue decided was whether the subject arbitration awards directing Allstate to reimburse Fireman's Fund for payment of no-fault benefits was arbitrary and capricious. The court held that the arbitration awards were not arbitrary and capricious, as Allstate failed to timely file a written answer and did not offer an explanation for its failure to do so. Therefore, the Supreme Court properly confirmed the arbitration awards in favor of the petitioner, Fireman's Fund Insurance Company.

The main issue in this case was whether the owner of an uninsured motorcycle can recover underinsurance benefits pursuant to an automobile policy issued to a member of his family household, when that policy contains an exclusion for uninsured "motor vehicles" owned by the insured. The court considered the fact that the insured, Lang, was involved in an accident while operating his uninsured motorcycle, and subsequently filed a claim for underinsurance benefits under a policy issued to family members he resided with, which was promptly disclaimed by the insurance company. Lang argued that the term motor vehicle and motorcycle were defined separately in the policy, but the court found that the exclusion in the policy was unambiguous and that Lang was precluded from recovering underinsurance benefits. The court held that as Lang was operating an uninsured motorcycle he owned at the time of the accident, he is precluded from recovering underinsurance benefits pursuant to the exclusion in the insurance policy's SUM endorsement. Therefore, the petition for a permanent stay of underinsurance arbitration demanded by Lang was granted.

The district court was considering a case where a plaintiff was seeking to recover no-fault first party benefits for acupuncture services provided to an assignor following a motor vehicle accident. The defendant, State Farm Mutual Auto Ins. Co., moved for summary judgment. The main issue the court decided was whether the defendant had demonstrated a timely and proper denial of the plaintiff's claim. The court held that the plaintiff's conclusory statements regarding the mailing of the denials were insufficient to establish their mailing, and that the defendant's representative's description of office practice did not ensure that items were properly addressed and mailed. Therefore, the court denied the defendant's motion for summary judgment.

The court considered a case in which plaintiff Friendly Physician, P.C. sought summary judgment to recover assigned first-party no-fault benefits, and defendant Progressive Insurance Company cross-moved to compel discovery. The main issue was whether the plaintiff had demonstrated that the no-fault claim forms underlying the action were admissible as business records within the meaning of CPLR 4518[a], in order to establish their entitlement to summary judgment. The court held that the plaintiff did not meet its burden to demonstrate the admissibility of the claim forms, as the affidavit submitted was insufficient and lacked details as to how the claim forms were generated. Therefore, the court denied plaintiff's motion for summary judgment and granted defendant's cross-motion to compel discovery, directing the plaintiff to serve answers to defendant's interrogatories within 45 days.

The main issue before the court was whether the defendant, State Farm Mutual Insurance Company, had provided enough evidence to demonstrate that there was an issue of fact as to whether the injuries claimed by the plaintiff's assignor were related to an insured incident. The court found that State Farm had submitted an affidavit from its investigator that was sufficient to demonstrate a "founded belief" that the alleged injuries did not arise from an insured incident. However, the court also noted that the defendant's submission consisted of hearsay and speculative assertions and did not satisfy its burden of demonstrating the existence of a triable issue of fact. Therefore, the judgment in favor of the plaintiff was reversed, and the matter was remanded for further proceedings. The court also noted that absent a timely and valid denial, the defendant was precluded from raising most defenses to a cause of action for payment of the claim.

The relevant facts considered by the court were that the plaintiff, Kings Highway Diagnostic Imaging, P.C., sought recovery of first party no-fault benefits from the defendant, Autoone Insurance Company, for medical services rendered to its assignors. The main issue decided by the court was whether the magnetic resonance imaging (MRI) tests of the plaintiff's assignor's cervical and lumbar spine were medically necessary. The court held in favor of the plaintiff in the amount of $1,791.00, as it found that the defendant's medical evidence demonstrated that the services were not medically necessary, but the plaintiff sufficiently rebutted the defendant's medical testimony and demonstrated the medical necessity of its claims. Therefore, judgment was entered in favor of the plaintiff with statutory interest, costs, and attorney fees.

The court considered an appeal from an order and judgment in favor of New York & Presbyterian Hospital in a case to recover no-fault benefits issued by American Transit Insurance Company. The main issue was whether the plaintiff was entitled to summary judgment in its favor. The holding of the case was that the Supreme Court should not have granted the plaintiff's motion for summary judgment, as the defendant raised a triable issue of fact as to whether the benefits were overdue. The defendant provided evidence that the plaintiff's claim for benefits was denied on the ground that the forms were submitted more than 45 days after the last date of medical service. Therefore, the motion for summary judgment was denied.

The main issue in this case was whether Plaintiff was collaterally estopped from enforcing a Default Judgment awarding No-Fault insurance benefits, based on a previous Declaratory Judgment from the Supreme Court. The court considered the fact that Plaintiff was not named in the Declaratory Judgment nor notified of its pendency, and had no opportunity to contest the determination. The court also analyzed the grounds for vacating a default judgment, as provided by Section 5015 of the CPLR, and took into consideration previous case law where judgments were vacated in the interests of justice. Ultimately, the court held that the entry of judgment was a nullity and vacated the default judgment, as questions of fact existed. In simpler terms, the court decided that Plaintiff could not be collaterally estopped from enforcing the No-Fault award, as Plaintiff was not a party to the previous Supreme Court action and had no opportunity to defend against the assertions. Additionally, the court vacated the default judgment because the Declaratory Judgment, along with the arguments presented by Defendant, raised questions of fact that precluded summary judgment. The court emphasized the importance of deciding issues after a full hearing on the merits, rather than by default, and exercised its discretion in vacating the judgment in the interests of efficient administration of justice.