No-Fault Case Law

The relevant facts in New York and Presbyterian Hospital v Travelers Property Casualty Insurance Company, include an action to recover no-fault medical payments, in which New York and Presbyterian Hospital, as the assignee of William Browne, and New York Hospital Medical Center of Queens, as assignee of Amy Kazane, were the plaintiffs. The main issue decided was whether the defendant's motion to vacate a judgment entered upon its failure to appear or answer the complaint, and for leave to serve a late answer, should be granted. The holding of the case was that the defendant was required to demonstrate both a reasonable excuse for the default and a meritorious defense, and the defendant made that showing. Therefore, the Supreme Court granted the defendant's motion to vacate the judgment and for leave to serve a late answer.

The relevant facts considered by the court in this case was an action to recover assigned first-party no-fault benefits. The plaintiff health care provider moved for summary judgment, while the defendant argued that the assignor failed to attend examinations under oath (EUOs) and that the accident was in furtherance of an insurance fraud scheme. The main issues decided were whether the EUO requests tolled the 30-day claim determination period, rendering the denial untimely, and whether the defendant failed to establish a triable issue of fraud regarding the accident being staged for a scheme to defraud. The holding of the case was that the order denying plaintiff's motion for summary judgment was reversed, and the matter was remanded to the court below for a calculation of the statutory interest and an assessment of attorney's fees. The dissenting opinion disagreed with the majority's finding, stating that the defendant should not have been required to produce a copy of the insurance policy, and would have affirmed the lower court's denial of the plaintiff's motion for summary judgment.

The court considered the parties' submissions and found that the plaintiffs were entitled to recover no-fault benefits in their action against the defendant. It was established that they met the requirements for statutory claim forms and that payment of no-fault benefits was overdue. An absence of an index number on one of the documents submitted was an improper ground to deny the relief sought, and the allegedly defective proof of assignments did not merit the motion's outright denial. Defendant was found to have failed to timely seek verification of the assignments and to have waived any defenses with respect to them. The claim denials for several specific claims were determined to be untimely. Additionally, defendant failed to provide proper verification request to toll the claim determination periods for certain other claims, and offered no proof that the insurance policy contained an endorsement authorizing such verification. Furthermore, some claims were denied on the ground of not being formed and operated in accordance with Article 15 of the Business Corporation Law, which was considered a defense sounding in fraud. The court ultimately held that summary judgment should have been granted as to the plaintiffs' claims, and partially modified the order of the Civil Court of the City of New York Kings County accordingly.

The court considered an order from the Civil Court of the City of New York that granted a defendant's motion to compel responses to a bill of particulars and discovery demands, and denied the plaintiff's cross-motion for summary judgment. The main issue decided was whether the defendant was entitled to compel the plaintiff to respond to the bill of particulars, the demand for records, and the request for an examination before trial. The holding was that the plaintiff established its prima facie entitlement to summary judgment by proof of submission of its claim, setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The court also determined that the purpose of a bill of particulars is to amplify the pleadings, limit the proof, and prevent surprise at trial, and found that the demand for a bill of particulars improperly contained numerous requests for evidentiary information. Therefore, the defendant was afforded the opportunity to serve an amended demand for the bill of particulars.

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 provided to its assignor. The plaintiff submitted claims, setting forth the fact and the amounts of the losses sustained, and payment of no-fault benefits was overdue. The main issue decided was whether the defendant was obligated to pay or deny the claim, and if the plaintiff and its assignor had failed to respond to timely requests for verification. The holding of the case was that since the plaintiff and its assignor did not respond to verification requests, the period within which the defendant was required to respond to plaintiff's claims did not begin to run, and any claim for payment was premature. As a result, the defendant's cross motion for summary judgment was granted, and the complaint was dismissed.

The relevant facts considered by the court in this case include an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignor. The issue decided was whether plaintiffs' assignor was required to appear for examinations under oath (EUOs) as part of the insurance policy and if the failure of plaintiffs' assignor to appear for EUOs constituted grounds for denial of no-fault benefits. The holding of the court was that defendant failed to establish that the insurance policy contained an endorsement authorizing EUOs, and therefore the failure of plaintiffs' assignor to appear for EUOs cannot constitute grounds for denial of no-fault benefits. The court also held that the defendant's submissions are insufficient to raise triable issues of fact pertaining to its defense of fraud. As a result, plaintiffs' motion for summary judgment was granted and the matter was remanded for the calculation of statutory interest and an assessment of attorney's fees.

The court considered an appeal from an order granting the plaintiff's motion for summary judgment in a first-party no-fault benefits action. The main issue was whether the plaintiff provider had established a prima facie entitlement to summary judgment by proof of submission of statutory claim forms to the defendant. The court held that the plaintiffs failed to establish that they submitted the claim forms to the defendant, as there were discrepancies between the claim forms attached to the plaintiff's moving papers and the defendant's denial of claim forms, which were not explained on the record. Therefore, the court reversed the order and denied the plaintiff's motion for summary judgment. A judge concurred with the result but disagreed with certain propositions of law set forth in cases cited in the majority opinion.

The court considered the fact that in this action to recover first-party no-fault benefits, the plaintiff had submitted a completed proof of claim and that payment of no-fault benefits was overdue. The main issue decided was whether the defendant was precluded from raising defenses due to not denying the claim within the 30-day prescribed period. The holding of the court was that the plaintiff's motion for summary judgment was granted and the matter was remanded for the calculation of statutory interest and assessment of attorney's fees pursuant to Insurance Law § 5106 and the regulations promulgated thereunder. The court emphasized that the defendant had failed to clearly and unequivocally meet even the simplest of burdens placed upon them by regulations and the courts, and that they persistently failed to meet timely deadlines and specific denials.

The main issue in this case was whether an insurance carrier was entitled to recoup first-party no-fault basic economic loss payments from defendants, allegedly non-covered persons, after the three-year statute of limitations for personal injuries had passed. The court considered whether the insurance carrier was entitled to the toll on the running of the statute of limitations provided by Insurance Law § 5104 (b). The court held that the defendants' motion to dismiss the action was properly denied because they presented insufficient evidence to establish that the action was excluded from the ambit of Insurance Law § 5104 (b). The court also noted that the defendants could raise the claim that the action was barred by the statute of limitations again if they could provide sufficient evidence that the plaintiff's subrogors had instituted a prior action against them, which would take the instant action outside of the tolling provisions set forth in Insurance Law § 5104 (b).

The issue in the case was a claim for first-party no-fault benefits by A.B. Medical Services PLLC in the sum of $3,971.20. The defendant in the case, GEICO Casualty Insurance Co., timely denied the claims in the respective sums of $1,972.08 and $1,999.12 on the grounds of failure to establish medical necessity. The court found that the specific reason for denying the claims were negative peer review reports. The court found that the denial of claim forms failed to set forth with sufficient particularity the factual basis and medical rationale for its denial based on a lack of medical necessity, and it is therefore precluded from asserting said defense. A.B. Medical thus had a prima facie entitlement to partial summary judgment in the sum of $3,971.20. On the other hand, the dissenting opinion of Golia, J. stated that the claimant waited six months to request the reports, but just two months to bring the action and that the failure of GEICO Casualty Insurance Co. to submit a sworn copy of the peer review report in opposition to the claimant's motion for summary judgment should not be fatal. Therefore, the court modified the order by providing that plaintiff's motion for summary judgment is granted to the extent of awarding plaintiff partial summary judgment in the sum of $3,971.20 and the matter was remanded to the court below for the calculation of statutory interest and assessment of attorney's fees thereon and for further proceedings on the remaining claim.