No-Fault Case Law

The relevant facts in this case involved a dispute over first-party no-fault benefits, with the plaintiff, a medical provider, seeking to recover these benefits from the defendant insurance company. The plaintiff submitted proof that the claim was mailed to the defendant on October 20, 1997, and the defendant failed to timely pay or deny the claim within the 30-day statutory period. Despite the defendant's denial of the claim form predating its receipt of the claim, the court found that such denial did not constitute a valid denial of no-fault benefits. The denial of claim form was also deemed defective due to its omission of numerous items of requested information and was therefore considered incomplete. As a result, the court granted the plaintiff's motion for summary judgment, reversed the order denying the motion, and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

The court considered the fact that Ocean Diagnostic Imaging P.C. was seeking to recover first-party no-fault benefits for medical services rendered to its assignor, Sofia Kandelaki. The main issue was whether Ocean Diagnostic Imaging P.C. had established a prima facie entitlement to summary judgment by proving that it submitted a claim, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The court held that Ocean Diagnostic Imaging P.C. did establish a prima facie entitlement to summary judgment, and therefore, their motion for summary judgment was granted. The matter was remanded to the court below for a calculation of statutory interest and an assessment of attorney's fees. The court further held that the defendant's assertion of a founded belief that the incident was not an accident but a deliberate event staged in furtherance of a scheme to defraud the insurer was not sufficient to demonstrate a triable issue of fact and did not defeat the plaintiff's motion for summary judgment.

Plaintiff health care provider East Acupuncture, P.C., sued defendant Allstate Ins. Co. to recover no-fault benefits for patients who were injured. They entered into a stipulation of settlement, but a dispute arose over the issue of when interest begins to accrue on an untimely denial and/or improper denial under the no-fault regulations. Plaintiff argued that interest on claims should accrue from 30 days after the insurer received a proper proof of claim, while defendant argued that interest should not accrue until the no-fault claimant requests arbitration or institutes a lawsuit. The court found that the regulation required a strict interpretation and the decision of the Superintendent to omit the word "assignee" within the regulation's application meant that it was clear the Superintendent intended to exclude assignees from its application, ruling in favor of the defendant.

The main issue in the case was whether the court had jurisdiction over a dispute regarding overdue no-fault benefits, statutory interest, and attorney's fees for medical testing services allegedly rendered by the plaintiff to Annette Brown as a result of a motor vehicle accident. The defendant argued for a change of venue from Nassau County to Sullivan County, and the plaintiff sought summary judgment against the defendant. The court held that it did not have jurisdiction to transfer actions to different counties and denied the defendant's request for a change of venue. It also found that the plaintiff did not establish a prima facie case for summary judgment, as the plaintiff's moving papers were deficient and no proof of mailing was furnished. Additionally, the court held that it did not have jurisdiction over the person of the defendant, as the defendant did not transact business within Nassau County, and the cause of action did not arise from any transaction of business in Nassau County. Therefore, the defendant's cross-motion to dismiss the plaintiff's complaint was granted, and the plaintiff's motion for summary judgment was denied, as was the defendant's cross-motion for summary judgment.

The court considered the action to recover no-fault medical payments, where the plaintiff was Nyack Hospital, as the assignee of Ray Rodriguez. The main issue was to determine whether the denial of plaintiff's motion for summary judgment and the granting of the defendant's cross motion for summary judgment dismissing the complaint were appropriate. The holding of the court was that the Supreme Court properly denied the plaintiff's motion for summary judgment and correctly granted the defendant's cross motion for summary judgment dismissing the complaint. The insurer was not obligated to pay or deny a claim until it had received verification of all relevant information requested, and since the defendant had not received the verification requested, any claim for payment was premature. Therefore, the period within which the defendant was required to respond to the plaintiff's claim did not begin to run.

The case involved an appeal by the plaintiffs from the denial of their motion for summary judgment and a cross-appeal by the defendant from the same order. The issues revolved around an action to recover assigned first-party no-fault benefits for medical services and whether the accident was employment-related. The court found that the insurer failed to establish the defense's "potential merit" to warrant Board review of the facts. As a result, the court granted the plaintiffs' motion for summary judgment and remanded the matter to the court for a calculation of the statutory interest and an assessment of attorney's fees. The court's ruling was based on evidence provided by the plaintiffs, as well as the lack of sufficient evidence presented by the defendant, which led to the denial of the proposed defense.

The court considered the fact that Careplus Medical Supply Inc. was seeking first-party no-fault benefits for medical supplies furnished to its assignor and had submitted claims for the loss sustained. Careplus established prima facie entitlement to summary judgment by providing proof of overdue payment of no-fault benefits. The main issue was whether the alleged injuries were causally related to the accident, which was asserted as a defense by Kemper Auto & Home Insurance Company. In opposition to the motion for summary judgment, Kemper Auto & Home Insurance Company presented an Accident Reconstruction Analysis report as admissible evidence by an expert in the field, which demonstrated a lack of causal nexus between the accident and the injuries claimed by Careplus' assignor. The court held that since Kemper demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, Careplus' motion for summary judgment was properly denied.

The court considered a motion brought by GEICO Insurance Company to consolidate 60 pending actions and to amend their answers in order to include a defense of fraud in the incorporation of the plaintiff professional corporation. The main issue was whether the health providers, incorporated by a physician and subject to a management agreement with nonlicensed professionals, violated both New York's Business Corporation Law and Education Law. The court held that any claims arising from accidents occurring under a policy previous to April 5, 2002, were subject to the old regulations, but the regulations could be imposed upon claims arising before that date, given the procedural posture of the no-fault claims. The court concluded that the defense of fraud in the incorporation is effective only if the insurer can show fraud by "fact or founded belief," and no reimbursement would be mandated if fraud was found. The court pointed out that the defense is effective only if the insurer initially shows fraud in the incorporation. Therefore, the defendant in the case articulated a "founded belief" that the health providers breached New York's Business Corporation Law and Education Law.

The main issue in this case was whether the plaintiff, a health care provider, was entitled to summary judgment to recover first-party no-fault benefits for medical services rendered to its assignor. The court considered the fact that the plaintiff had submitted a claim for the medical services and that payment of the benefits was overdue. The defendant had timely denied the claim but had to submit proof in admissible form to rebut the plaintiff's prima facie showing. The court found that the defendant had raised a triable issue of fact as to whether it was provided with notice of the accident within 90 days as required by the insurance regulations. Therefore, the court affirmed the decision to deny the plaintiff's motion for summary judgment, as the defendant had sufficiently rebutted the plaintiff's showing.

The relevant facts considered by the court in this case were that the plaintiff filed a lawsuit to recover first-party no-fault benefits that were assigned to him by an injured party. The plaintiff was granted summary judgment, but the defendant appealed. The main issues decided in this case included whether the plaintiff had established entitlement to summary judgment, whether the defendant had failed to deny the claim within the required 30 days, and whether the defendant had provided sufficient proof of verification requests. The holding of the case was that the defendant did not raise a triable issue of fact and the plaintiff's motion for summary judgment was denied. The court also found that the defendant's untimely denial precluded certain defenses, but allowed the defendant to argue that the claim was based on treatment for medical conditions unrelated to a covered traffic incident.