No-Fault Case Law

The court considered the case of A.B. Medical Services PLLC et al. as assignee of Sahara Abbott, who were appealing against Utica Mutual Insurance Company. The claimants were seeking partial summary judgment in the sums of $6,765.47 and $1,690.56 respectively. The main issues decided by the court were whether the defendant violated the 30-day claim determination period and precluded itself from interposing most defenses as to all claims mailed on or before November 2, 2002, and whether they demonstrated a tolling via proof that one or more of the notice of physical examination letters were issued and the plaintiffs failed to appear. The holding of the court includes the modification of the order by granting the plaintiffs' partial summary judgment in the declared sums and remanding other claims to the court below for a calculation of statutory interest and an assessment of attorney's fees. The appeal as taken by plaintiff Square Synagogue Transportation Inc. was unanimously dismissed. The court determined that the defendant failed to establish a triable issue of fraud and proper verification requests with respect to its letters, and that the letters issued were ineffective to toll the 30-day claim determination period.

The relevant facts considered by the court were that plaintiff, a healthcare provider, submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that defendant insurance company failed to pay or deny the claim within the prescribed period. The main issue decided was whether defendant was precluded from raising certain defenses due to the untimely denial of the claim, and whether the defense of insurance fraud scheme could be asserted. The holding of the case was that plaintiff was not entitled to summary judgment because defendant raised a triable issue of fact as to whether there was a lack of coverage, and the court erred in granting plaintiff's motion for summary judgment.

The court considered whether a statutory arbitration proceeding to resolve a coverage dispute concerning an uninsured motorist claim is a claim founded upon a tort requiring the service of a notice of claim as a condition precedent to the commencement of an action. The main issue decided was whether a self-insured municipality is required to provide mandatory uninsured motorist benefits to employees who operate municipal motor vehicles. The holding was that although the lower court erred in dismissing the petition for failure to comply with a particular law, the court never reached the issue, so the matter was remitted to the Supreme Court for a framed issue hearing to determine whether the municipality received notice given by or on behalf of the injured person as soon as was reasonably practicable. In light of that determination, the appellant's remaining argument was considered academic.

The court considered a series of complaints filed by medical providers seeking a money judgment against an insurance company for recovery of no-fault medical benefits rendered to its assignor, plus interest and attorneys' fees. The insurance company interposed an Answer alleging several affirmative defenses, including misrepresentation, unlawful practice of medicine, lack of standing, and fee splitting. The insurance company also served a demand for written interrogatories and notice of examination before trial. The court ultimately decided that the insurance company was not entitled to depose Dr. Nandi or the treating acupuncturists because the insurance company failed to preserve any defense of fraud in its denial and defendant's submission lacked reliable foundation to infer that the medical providers were engaging in behavior that can be described as "tantamount to fraud." The main issue decided by the court was whether the insurance company was entitled to depose Dr. Nandi and the treating acupuncturists to obtain evidence of the entities' corporate structure and method of payment and sum of salaries. The court held that the insurance company was not entitled to the depositions it sought, as it failed to demonstrate that the defense of fraudulent incorporation and unlawful fee-spitting was well-founded and in good faith. The court granted the plaintiffs' cross-motion for a protective order and denied the insurance company's motion to dismiss the complaints or to compel plaintiffs to provide outstanding discovery.

The relevant facts considered by the court were that Mega Supply & Billing, Inc., a medical provider, was seeking to recover first party No-Fault benefits from American Transit Insurance Co. The main issue decided was whether the insurer had properly denied the benefits and if the reason for the denial was legally sufficient. The holding of the case was that the explanation provided by the insurer for denying the first-party benefits was not specific enough, and therefore, unable to overcome the plaintiff's motion for summary judgment. The court ordered the clerk to enter a judgment in favor of the plaintiff in the amount of $1024, plus interest, costs, and attorneys' fees.

The court considered whether it is appropriate to grant leave to a plaintiff billing provider to amend a fatally defective proof of claim once an action to recover on the claim has been commenced. The main issue decided was that the provisions of 11 NYCRR 65.15 (j) (1) prohibits a billing provider from recovering assigned first-party no-fault benefits where the medical services were performed by an independent contractor. The court held that this defense is not waivable and is therefore not subject to the preclusion rule, as stated in Rockaway Blvd. Med. P.C. v Progressive Ins. The holding of the case was that the motion to amend the NF-3 proof of claim forms was denied, and judgment was ordered to be entered in favor of the defendant dismissing the entire action.

The court considered the fact that Careplus Medical Medical Supply Inc. filed a lawsuit against Allstate Insurance Company in an effort to recover first-party no-fault benefits for medical supplies rendered to several individuals. The main issue decided was whether Careplus was entitled to summary judgment in regard to causes of action relating to two of the assignors, Romana Hernandez and Jaime Diaz. The court ultimately held that Careplus did establish a prima facie entitlement to summary judgment with regard to the causes of action relating to Romana Hernandez and Jaime Diaz. However, Allstate Insurance Company was not precluded from asserting the defense that the various collisions were in furtherance of insurance fraud schemes, despite the untimely denials of the claims. The court reversed the order granting plaintiff's motion for summary judgment and denied the motion in causes of action relating to Romana Hernandez and Jaime Diaz.

The case of Matter of State Farm Mutual Automobile Insurance Company v City of Yonkers involved State Farm's attempt to vacate an arbitration award in favor of the City of Yonkers in the sum of $49,962.88, that was issued as a result of a worker's compensation claim. The key issue was whether the general release signed by the injured individual extinguished the City's ability to seek recovery of the worker's compensation benefits through a process known as loss transfer. Ultimately, the court held that the general release executed by the injured party did not waive the City's right to seek recovery of benefits through loss transfer, and that the arbitrator's determination was supported by evidence. The court also found that the arbitrator's award complied with procedural requirements and should have been confirmed. The dissenting opinion argued that the arbitrator's decision was incomprehensible and did not comply with procedural requirements, and that the issue of explicit waiver of the right to loss transfer recovery was not adequately considered.

The court considered the fact that the plaintiff had established its entitlement to summary judgment by submitting the functional equivalent of the statutory claim forms, setting forth the fact and amounts of the losses sustained, and that payment of no-fault benefits was overdue. The main issue decided was whether the defendant's failure to pay or deny the claims within the statutory 30-day claim determination period precluded its defenses, and whether the defendant's denials of most of the remaining claims on the ground that the sums sought for the items of medical equipment exceeded an alleged average of suppliers' prevailing rates in the plaintiff's geographic location were without merit. The holding was that the order denying the plaintiff's motion for summary judgment was reversed, and the matter was remanded to the court below for a calculation of statutory interest and an assessment of attorney's fees. Plaintiff's motion for summary judgment was granted.

The relevant facts considered by the court were that the plaintiff was seeking recovery of first-party no-fault benefits for medical equipment furnished to its assignors. The main issue decided was that the plaintiff established its entitlement to summary judgment by submitting the functional equivalent of the statutory claim forms and proving that payment of no-fault benefits was overdue. The court held that the defendant's claim that the plaintiff failed to prove that its assignors are covered by a policy issued by the defendant was without merit as the burden shifted to the defendant to raise a triable issue of material fact. The court also found that the defendant's partial denials of the claims based on exceeding supposed average of suppliers' prevailing rates were improper and that the defense based on defective assignments was waived by the defendant's failure to seek verification of the assignments or to allege any deficiency in the assignments in its claim denial forms. The court reversed the order denying summary judgment, granted plaintiff's motion for summary judgment, and remanded the matter to the court below for a calculation of statutory interest and an assessment of attorney's fees.