No-Fault Case Law

The court considered the fact that the plaintiff had submitted a statutory claim form for first-party no-fault benefits for medical services provided to the injured assignor. The main issue decided was whether the defendant had established that verification requests were timely mailed. The court held that the defendant failed to prove the timely mailing of the verification requests and did not create a presumption of mailing by providing evidence of the standard operating procedures used to ensure that the verification requests were mailed. As a result, the court affirmed the order granting the plaintiff's motion for summary judgment and denying the defendant's cross motion.

The court considered the fact that Ocean Diagnostic Imaging had submitted claims for first-party no-fault benefits for medical services rendered to its assignors for injuries sustained in accidents in February and May 2003. The main issue decided was whether Ocean Diagnostic Imaging had established its entitlement to summary judgment by submitting claims and whether the insurance company had waived any defenses by failing to seek verification of the assignments. The holding of the case was that Ocean Diagnostic Imaging had established its entitlement to summary judgment and that the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees. The court also emphasized the principle that once a party affirmatively establishes an issue of fact, the other side must oppose it either factually or on legal grounds, or else that issue will be determined in favor of the proponent.

The relevant facts the court considered in this case were that Allstate Insurance Company sought to confirm an arbitration award in the principal sum of $17,348.79 against Republic Western Insurance Company, in a subrogation claim arising from an accident involving a U-Haul vehicle. The main issue decided was whether Republic Western had waived its right to contest the arbitrability of the claim by failing to apply for a stay of arbitration prior to arbitration. The holding of the case was that Republic Western had indeed waived its right to challenge the arbitrability of the claim, as it did not apply for a stay of arbitration prior to arbitration and did not conclusively establish that the U-Haul vehicle involved in the accident did not meet the weight requirements necessary to trigger the no-fault benefits authorized by the statute.

The relevant facts that the court considered were that plaintiff health care provider submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that payment of the benefits was overdue. The main issue decided was whether the defendant could establish that the denial was timely mailed within the 30-day prescribed claim determination period. The holding of the case was that the defendant failed to provide proof or an affidavit establishing that the denial was sent to the plaintiff, and therefore the court affirmed the order granting the plaintiff's motion for summary judgment. The defendant was precluded from raising the defense that the procedure was not medically necessary because it neither denied the claim within 30 days of receipt nor effectively extended the 30-day period.

The relevant facts considered by the court were that the plaintiff health care provider submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that the payment of these benefits was overdue. The main issue decided was whether the failure of one of the plaintiff's assignors to appear for an examination under oath (EUO) precluded summary judgment, and whether the defendant's untimely denial of another claim precluded the defense that the collision was in furtherance of an insurance fraud scheme. The holding of the court was that plaintiff was entitled to summary judgment upon both claims, as the defendant failed to establish that it possessed a "founded belief that the alleged injuries do not arise out of an insured incident," and that the defendant did not submit sworn statements establishing those findings as required by the Court of Appeals. The court affirmed the order without costs, with one justice dissenting.

The court considered the fact that the plaintiff was seeking recovery of no-fault benefits for an assignor as a result of a 2001 automobile accident. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The court held that the defendant's motion for summary judgment should have been granted, as neither the plaintiff nor their assignor submitted written notice of the accident to the defendant within the required 90-day period, nor did they provide proof that they were unable to comply with the time limitation due to circumstances beyond their control. The court also noted that the lower court disposed of the motion without providing any explanation or reason for its decision, which was a practice to be avoided.

The court considered whether defendant Progressive Northeastern Insurance Company had an obligation to provide insurance coverage to defendant Charles Young in connection with underlying claims by defendant Amber M. Wood for personal injuries allegedly caused to her by defendant Young's motor vehicle. The main issue was whether Progressive had an obligation to provide insurance coverage to Young based upon his "intentional act" which constitutes an exclusion from coverage under Young's automobile insurance policy with Progressive. The court held that Progressive's intentional act exclusion did not apply and that Progressive must defend and provide insurance coverage for Young, as the incident should be considered an "accident" under the definitions of Young's insurance policy. The court further declared that Progressive must provide liability insurance coverage to Young and no-fault insurance coverage for Wood.

The court considered that the petitioner, Patricia A. Snyder, had been injured in a motor vehicle accident in 1996 while working for her employer and had received workers' compensation benefits from her employer's insurance carrier, CNA Insurance Companies, as well as first-party benefits pursuant to the no-fault provisions of the Insurance Law. After settling a third-party negligence action against the driver of the other vehicle involved in the accident for $32,500, Snyder failed to obtain consent of the settlement from respondent CNA Insurance Companies as required by law. The main issue decided by the court was whether Snyder's request for judicial approval, nunc pro tunc, of the third-party settlement should be granted. The holding of the case was that the Supreme Court had not abused its discretion in approving the settlement, as it found that it would have been difficult for Snyder to prove that she had suffered a serious injury as a result of the accident and that respondent had suffered no prejudice from her delay in seeking approval. Therefore, the order granting approval of the settlement was affirmed.

The main issue in Allstate Ins. Co. v Belt Parkway Imaging, P.C. is whether the insurance companies can withhold payment for medical services provided by fraudulently incorporated enterprises and if they can bring actions for fraud and unjust enrichment to recover payments made after a particular regulation's effective date. The court considered the fact that the insurance carriers could sue for fraud and unjust enrichment to recover payments made after the regulation's effective date. The holding of the case was that the insurance companies could withhold payment for medical services that fraudulently incorporated enterprises provided and to which patients have assigned their claims, as well as bring actions for fraud and unjust enrichment to recover payments made after the regulation's effective date. Also, the court deemed it appropriate to certify the question to the New York Court of Appeals regarding the entitlement of a fraudulently incorporated medical corporation to be reimbursed by insurers.

The relevant facts that the court considered in this case were that Mount Sinai Hospital brought a suit against Allstate Insurance Company to recover no-fault medical payments under an insurance contract. The main issue in the case was determining whether Allstate had failed to pay or deny Mount Sinai's claim for no-fault medical payments within 30 days as required by 11 NYCRR 65-3.8 (c), as well as whether Mount Sinai had complied with a demand for verification in accordance with 11 NYCRR former 65.15 (g) (1) (i) and (2) (iii). The holding of the case was that the court modified the order and granted Allstate's request for summary judgment, as they had raised a triable issue of fact regarding Mount Sinai's compliance with the demands for verification. The court agreed that any claim for payment was premature until it was established when the 30-day period within which Allstate was required to respond began to run, and as such, the order was modified, and the case was affirmed.