No-Fault Case Law

The court considered the fact that the plaintiff settled his personal injury case and subsequently sued his own insurer, State Farm Mutual Automobile Insurance Company, to recover damages under the supplementary underinsured motorist endorsement of his policy. State Farm raised the affirmative defense that the plaintiff did not sustain a serious injury within the meaning of Insurance Law section 5102 (d), arguing that its policy contained an exclusion requiring the policy holder to sustain a serious injury to recover SUM benefits. The court decided that the insurer cannot raise the defense of lack of serious injury as the plaintiff was not required to demonstrate a serious injury for his breach of contract action against his insurer to recover benefits under the optional, underinsurance endorsement of his insurance policy. The court held that the serious injury threshold was not mandated by law and therefore less favorable to the insured than section 3420 (f) (2) and should not be given effect. Therefore, State Farm's defense was stricken, and the order of the Supreme Court was affirmed.

The court considered that the plaintiff, a health care provider, had submitted evidence that the prescribed statutory billing forms had been mailed and received and that payment of no-fault benefits was overdue. The main issue decided was whether the plaintiff had established a prima facie entitlement to summary judgment, and the court held that they had, as they had shown proof that the billing forms had been properly addressed and mailed and that payment was overdue. The court also considered the defendant's failure to raise any triable issues of fact in opposition to the plaintiff's motion for summary judgment. In the end, the court affirmed the order granting plaintiff's motion for summary judgment and held defendant responsible for $10 in costs.

The relevant facts considered by the court in Accurate Med., P.C. v Travelers Insurance Co. were that the defendant had served the plaintiff with a notice of deposition and written discovery demands in August 2004, yet did not object to the plaintiff's written interrogatories, nor did they conduct the plaintiff's deposition. Plaintiff then filed a notice of trial in April 2006. The main issue decided was whether the defendant's failure to object to plaintiff's written interrogatories and conduct their deposition, despite being served with a notice of deposition and discovery demands, warranted vacating the notice of trial. The holding of the case was that the motion to vacate the notice of trial was properly denied, as defendant failed to show the need to conduct a deposition. Therefore, the decision and order of the court was to affirm the denial of the motion to vacate the notice of trial.

The relevant facts that were considered in this case surrounded the denial of a claim for an MRI in the amount of $879.73 that was submitted by the plaintiff to the defendant, Allstate Insurance Company. The main issue that was decided was whether the defendant had the legal grounds to deny the claim on the basis that it arose from a staged event. The holding of the court was that the defendant did not provide sufficient evidence to support their belief that the accident was staged, and therefore granted summary judgment in favor of the plaintiff. The court awarded the plaintiff the sum of $879.73 plus interest at the statutory rate from the date of receipt of the claim, as well as attorney's fees.

The court considered the plaintiff's motion for summary judgment to recover No-Fault benefits, statutory interest, and attorney's fees, as well as the defendant's cross-motion for the same relief based on the argument that the services were not medically necessary. The main issue decided was whether the plaintiff had provided sufficient evidence to demonstrate entitlement to No-Fault benefits and whether the defendant had proven that there were triable issues of fact with regards to the medical necessity of the services provided. The holding of the case was that the plaintiff's motion for summary judgment was granted only as to the claim for attorney's fees for one of the amounts, while the defendant's cross-motion for summary judgment was denied. The court found that issues of fact existed regarding the medical necessity of the claims in the other amounts.

The case involved Allstate Insurance Company and Belt Parkway Imaging, P.C. The main issue was whether Allstate had the right to withhold payments for claims made by Belt Parkway Imaging, P.C. before April 4, 2002. The court held that Allstate could indeed withhold payments for those claims, and dismissed the causes of action for fraud and unjust enrichment regarding payments made before April 4, 2002. This decision was based on an Insurance Department regulation that stated a provider of health care services is not eligible for reimbursement if they fail to meet the necessary licensing requirements. The Court of Appeals upheld this regulation, allowing insurance carriers to withhold payment for medical services provided by fraudulently incorporated enterprises, and stated that no cause of action for fraud or unjust enrichment would lie for payments made before the regulation took effect. The court found this regulation did not impair vested rights or create a new right.

The court considered the case of SpineAmericare Medical, P.C. v State Farm Mutual Automobile Insurance Company, in which the plaintiff was seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff had established its prima facie entitlement to summary judgment by proving the submission of statutory claims forms and that payment of no-fault benefits was overdue. The holding of the case was that the plaintiff's motion for summary judgment was granted to the extent of awarding partial summary judgment in the principal sum of $5,404.38. The matter was remanded for the calculation of statutory interest and an assessment of attorney's fees, as well as for further proceedings on the remaining claims. The court found that the plaintiff's moving papers were insufficient to establish the mailing of the forms to the defendant, but the defendant's letters to plaintiff adequately established that the defendant had received 10 of the 12 claims being sued upon.

The relevant facts the court considered in this case were that the plaintiff was seeking to recover first-party no-fault benefits for medical services rendered to its assignor. The plaintiff had submitted the claims and proof that the payment of the benefits was overdue. The main issue decided was whether the defendant had established a triable issue of fact and whether the defendant had mailed a timely denial of claim form to the plaintiff. The holding of the case was that the plaintiff's motion for summary judgment should have been granted because the defendant failed to establish that it mailed a timely denial of claim form to the plaintiff, and as a result, the defendant was precluded from raising the defense of lack of medical necessity. The matter was remanded to the court for the calculation of statutory interest and an assessment of attorney's fees.

The court considered the stipulated facts submitted by the parties in a case where Dependable Ambulette, Inc. sought to recover sums for transportation services rendered after April 5, 2002, based on automobile insurance policies that contained assignability clauses. The main issue decided was whether the NYS Insurance Commissioner's April 5, 2002 amendment to Art. 68 terminated existing policy endorsements, and if the Regulation 68 amendment barred the assignability of ambulance transportation services. The holding of the case was that the April 5, 2002 amendment voided any existing policy assignment language as "contrary to public policy", and the Court dismissed the plaintiff's complaint based on this conclusion.

The relevant facts considered by the court were that a health care provider brought an action to recover assigned first-party no-fault benefits. The court found that the attorney's affirmation in support of the motion for summary judgment lacked probative value as it did not lay a sufficient foundation to establish personal knowledge. The court also noted that defendant's opposition to plaintiff's motion for summary judgment demonstrated the existence of a triable issue of fact as to whether the alleged injuries did not arise out of an insured incident. The main issue decided was whether plaintiff's motion for summary judgment was supported by competent evidence to establish a prima facie case, and whether there was a triable issue of fact for the alleged injuries. The holding of the court was that plaintiff's motion for summary judgment was denied, and the order entered September 16, 2005 was vacated.