No-Fault Case Law

The Appellate Court considered the case of Active Care Medical Supply Corp. v. Global Liberty Insurance, in which the plaintiff was seeking to recover assigned first-party no-fault benefits. The issue before the court was whether the Worker's Compensation was primary in determining the liability for the benefits. After a nonjury trial, the court found in favor of the plaintiff, ruling that the defendant's certified transcript of an examination under oath of the plaintiff's assignor was not admissible based on law of the case. The defendant then moved to set aside the decision and for a new trial, pursuant to CPLR 4404, but this was denied by the Civil Court. The Appellate Court reversed the decision of the Civil Court, holding that it should have considered the certified EUO transcript to determine whether the defendant had proffered sufficient evidence to support its contention that there was an issue as to whether the plaintiff's assignor had been acting in the course of his employment at the time of the accident. Therefore, the defendant's motion for a new trial was granted.

The Court considered whether the failure of an eligible injured person (EIP) to attend an independent medical examination (IME) is a "policy issue" for the purpose of the no-fault insurance law denial of claim form and an award of hourly attorneys' fees under the New York Insurance Department Regulations. The main issue decided was that an EIP's failure to attend an IME is indeed a "policy issue" and plaintiff may be awarded attorneys' fees pursuant to the regulations. It was concluded that the insurer who denies a claim for first-party No-Fault benefits on the basis of the injured person's failure to attend an IME properly does so by checking the specific box on the denial of claim form, and so it is considered a "policy issue" for the purposes of awarding attorneys' fees under the regulations. The holding was that, while plaintiff may be awarded attorneys' fees in this case under the regulations, it is entirely unclear from the record whether the amount that was awarded was calculated correctly. Therefore, the matter was remanded for further proceedings and for an amended judgment.

The court considered a case in which a medical provider was seeking to recover no-fault benefits for services provided to its assignor who was injured in a motor vehicle accident. The insurance company, the defendant, had obtained a default judgment in a declaratory judgment action in Supreme Court, New York County, which declared that the insurer had no duty to pay any no-fault benefits to the provider and its assignor arising out of the accident. The issue in the case was whether the medical provider's action was barred under the doctrine of res judicata due to the declaratory judgment obtained by the insurance company in a separate action. The court held that the medical provider's action was indeed barred by res judicata, and reversed the order denying the insurance company's motion for summary judgment, granting the motion instead.

The court considered the fact that the defendant insurance company appealed from an order of the Civil Court that denied their motion for summary judgment dismissing the complaint of the plaintiff, a provider seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff's assignor failed to appear for duly scheduled examinations under oath (EUOs) and whether the defendant was entitled to summary judgment dismissing the complaint. The holding of the case was that the defendant insurance company was entitled to summary judgment dismissing the complaint, as they were able to demonstrate, as a matter of law, that they had twice duly demanded an EUO from the assignor, and that the assignor twice failed to appear. Consequently, the court reversed the order and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the fact that Restorative Chiropractic Solutions, PC brought a lawsuit against State Farm Mutual Automobile Ins. Co. to recover first-party no-fault benefits for medical services provided to its assignor, Lourdes Clyne. The main issue decided was whether the denials of the claims by State Farm Mutual Automobile Ins. Co. were timely and whether there was material misrepresentation in the procurement of the policy. The court held that while the bills were timely submitted and the denials were timely issued, there was an issue of fact as to whether the misrepresentation about the assignor's residence and garaging of the vehicle was material in the procurement of the insurance policy, indicating that the issues preserved for trial are the basis for the timely denials. The defendant’s motion for summary judgment and plaintiff’s cross motion were both granted.

The relevant facts considered by the court were that Physiodynamics, LLC was seeking to recover assigned first-party no-fault benefits from Allstate Ins. Co. A judgment was entered against Allstate on October 4, 2017 for failing to appear or answer the complaint. Allstate subsequently moved to vacate the default judgment. The main issue decided by the court was whether Allstate had a reasonable excuse for the default and the existence of a meritorious defense, as required by CPLR 5015 (a) (1) for vacating a default judgment. The court held that Allstate did not sufficiently allege a reasonable excuse of law office failure and therefore, their motion to vacate the default judgment should have been denied. The holding of the case was that the order granting Allstate's motion to vacate the default judgment was reversed, and the motion was ultimately denied.

In the case of RX Warehouse Pharm., Inc. v 21st Century Ins. Co., the plaintiff, RX Warehouse Pharmacy, Inc., sought to recover first-party no-fault benefits for services rendered to an injured party involved in a motor vehicle accident. Defendant 21st Century Insurance Company moved for summary judgment, arguing that the issue of providing no-fault coverage had been previously decided in a declaratory judgment action. The Supreme Court had previously granted 21st Century's motion for the entry of a default judgment, which the plaintiff argued was not applicable to them. The Civil Court ultimately denied 21st Century's motion and granted the plaintiff's cross motion for summary judgment, finding that the previous judgment did not conclusively determine a lack of coverage. The main issue decided in this case was whether the previous declaratory judgment action, in which 21st Century had been granted a default judgment, barred the plaintiff from seeking no-fault benefits for the injured party. The holding was that the previous default judgment in the declaratory judgment action did bar the plaintiff from seeking no-fault benefits, and therefore the defendant's motion for summary judgment was granted and the plaintiff's cross motion for summary judgment was denied.

The court considered a dispute over no-fault insurance benefits resulting from a motor vehicle accident. The plaintiff sought to recover $4,748.69 for treatment provided following the accident in April 2011, but the defendant argued that the benefits under the no-fault policy had been exhausted. The main issue decided was the requirement that an insurer pay or deny a verified claim within 30 days of receipt, as well as the insurer's obligation to pay benefits directly to providers of health care services. The holding of the court was that the defendant failed to establish its entitlement to judgment as a matter of law, as it did not submit the no-fault application, verification, any request for verification, or any denial associated with the plaintiff's claim for payment, and therefore there were remaining issues of fact as to when the claim was denied and the basis and efficacy of the denial.

The court considered the fact that the defendant had scheduled independent medical examinations (IMEs) of the plaintiff's assignor, and the assignor failed to appear for the duly scheduled IMEs. The main issue decided was whether the defendant had timely denied the claim based on the assignor's failure to appear for the IMEs, which was considered a condition precedent to the insurer's liability on the policy. The holding of the case was that the defendant had properly scheduled the IMEs and timely denied the claim, and therefore the motion for summary judgment dismissing the complaint was granted.

The relevant facts of the case were that PDG Psychological, P.C. sought to recover assigned first-party no-fault benefits from State Farm Mutual Insurance Co. State Farm moved to dismiss the complaint on the ground of laches, arguing that PDG Psychological, P.C. had delayed in prosecuting the action. The Civil Court granted State Farm's motion, but PDG Psychological, P.C. appealed the decision. The main issue decided by the court was whether the delay in prosecuting the action constituted laches. The holding of the case was that the order granting State Farm's motion to dismiss the complaint on the ground of laches was reversed. The court denied the branch of the motion seeking dismissal on the ground of laches and remitted the matter to the Civil Court for a determination of the remaining branch of State Farm's motion. The court also referenced a previous case, V.S. Med. Servs., P.C. v State Farm Mut. Ins. Co., to support its decision.