No-Fault Case Law
Matter of Nationwide Mut. Ins. Co. (Mackey) (2006 NY Slip Op 00205)
January 12, 2006
The main issue in the case was whether Nationwide Mutual Insurance Company was justified in denying coverage to Penny Mackey and Deanna Delaney under the policy's supplemental uninsured motorist (SUM) coverage. Mackey's daughter, Delaney, was injured in a car accident, and Mackey's attorney notified Nationwide of the potential SUM claim. Nationwide sent a "Proof of Claim" form in January 2004, but did not receive it back until April 2004 due to its misplacement. Nationwide then disclaimed coverage, arguing that the form was not returned as soon as practicable. The court held that since Mackey's attorney had promptly notified Nationwide of the claim and provided all necessary documentation, and Nationwide had not proven prejudice, it was unjust for the company to disclaim SUM coverage. The court therefore affirmed the lower court's decision denying Nationwide's application to stay arbitration and ruled in favor of Mackey and Delaney, holding Nationwide responsible for the SUM coverage.
Fair Price Med. Supply, Inc. v St. Paul Travelers Ins. Co. (2006 NY Slip Op 52598(U))
January 5, 2006
The relevant facts the court considered in this case were that the plaintiff, a medical provider, sought payment for medical services rendered to an assignor, which was rejected by the defendant-insurer on the grounds of lack of medical necessity. At trial, the plaintiff's bills were not accepted into evidence because its computer copies were unsigned. The defendant's interrogatories, however, established that a deficiency in the amount of $1261.81 remained outstanding. The main issue decided by the court was whether the plaintiff met its prima facie burden by a preponderance of the credible evidence. The holding of the court was that the plaintiff did indeed meet its burden, and the court directed the Clerk to enter judgment for the plaintiff in the amount of $1261.81, together with statutory interest, attorney's fees, and costs.
V.S. Med. Servs., P.C. v Allstate Ins. Co. (2006 NY Slip Op 26000)
January 3, 2006
The court considered evidence including witness testimony and reports from an investigator and claims representative to determine if the alleged accident was staged or not as part of an insurance fraud scheme. The main issue decided was whether a collision was a true accident and unintentional, regardless of the motivation behind it. The holding of the case was that the deliberate or intentional nature of the accident determines whether the incident is eligible for no-fault coverage, and not whether it was in furtherance of an insurance fraud scheme. This means that if the collision was deliberate, it would not be covered under the no-fault policy.
American Ind. Ins. v Gerard Ave. Med. P.C. (2005 NY Slip Op 52302(U))
December 31, 2005
The main issue in this case was whether the arbitrator had the power to award respondent benefits payable by petitioner. The relevant facts the court considered included the petitioner's contacts with New York, the requirement that insurers submit to arbitration, the arbitration award, and other relevant facts. The holding of the court was that the issue at hand was not whether the court had jurisdiction over petitioner, but whether the arbitrator did, or had the power to award respondent benefits payable by petitioner. As the facts determinative of this issue were absent, the court denied the petition to vacate the arbitration award.
Jeffrey I. Rubin, Phd Psyc. Svcs., P.C. v Utica Mut. Ins. Co. (2005 NY Slip Op 52206(U))
December 30, 2005
The main issue in this case was whether the defendant insurance company, Utica Mutual Ins. Co., was entitled to deny payment for first-party no-fault benefits for health care services rendered by the plaintiff health care provider. The plaintiff established a prima facie entitlement to summary judgment by proving that it submitted claims for the services and that payment of no-fault benefits was overdue. The defendant failed to pay or deny the claims within the prescribed 30-day period, precluding them from raising most defenses. However, the defendant was not precluded from asserting the defense that the alleged injuries did not arise out of an insured incident. The court ruled that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, therefore the plaintiff's motion for summary judgment was denied, and the order was reversed without costs.
Berger v Liberty Mut. Ins. Co. (2005 NYSlipOp 52204(U))
December 30, 2005
The relevant facts the court considered were that 11 plaintiffs were seeking to recover attorney's fees and interest on 14 first-party no-fault claims from Liberty Mutual Insurance Company. The claims were based on 14 unrelated assignors involved in accidents on 14 different dates, with no common contract of insurance between the claims. The main issue before the court was whether the causes of action should be severed, and if the court below should have determined the summary judgment motion on behalf of one of the plaintiffs. The holding of the case was that the court did not abuse its discretion in severing the causes of action for the sake of convenience, and the case was remanded for the court below to determine the summary judgment motion on behalf of one of the plaintiffs.
Gribenko v Allstate Ins. Co. (2005 NYSlipOp 52201(U))
December 30, 2005
The relevant fact that the court considered was that a health care provider submitted a claim for payment of no-fault benefits and that there was a dispute over whether the claim forms were actually mailed to the insurance company. The main issue decided was whether the health care provider had established a prima facie case that the claim forms were properly sent and that the insurance company failed to pay or deny the claims within the required time period. The holding of the case was that the health care provider had failed to provide competent proof that the claim forms were submitted to the insurance company, and therefore, they did not make the requisite showing to establish a prima facie entitlement to summary judgment. As a result, the order granting the motion for summary judgment was reversed, and the insurance company's motion for summary judgment was denied.
Ocean Diagnostic Imaging P.C. v AIU Ins. Co. (2005 NY Slip Op 52200(U))
December 30, 2005
The relevant facts considered by the court in this case were that Ocean Diagnostic Imaging P.C. sought to recover first-party no-fault benefits for medical services rendered to its assignor. The plaintiff established a prima facie entitlement to summary judgment by demonstrating that it had submitted claims for the losses sustained and that the payment of benefits was overdue. The main issue decided by the court was whether the defendant, AIU Insurance Company, was precluded from raising defenses due to its failure to pay or deny the claims within the prescribed 30-day period. The holding of the court was that while the defendant was precluded from raising most defenses, it could assert the defense that the alleged injuries did not arise out of a covered accident. The court found that the defendant had demonstrated the existence of a triable issue of fact as to the lack of coverage, and therefore, the plaintiff's motion for summary judgment was properly denied.
Mega Supply & Billing Inc. v Allstate Ins. Co. (2005 NY Slip Op 52168(U))
December 30, 2005
The relevant facts considered by the court included the plaintiff's motion for summary judgment to recover no-fault benefits from the defendant in the amount of $540.00, which the defendant failed to pay or deny within the required 30-day period. The main issue decided by the court was whether the defendant had a valid basis to toll the 30-day period for payment of benefits. The court also considered the defense of lack of medical necessity and the assertion by the defendant that the accident was staged in order to deny the claim. The holding of the case was that the plaintiff's motion for summary judgment was granted, and the court directed the clerk to enter judgment in favor of the plaintiff in the sum of $540.00, statutory interest, and attorney's fees.
St. Vincent’s Hosp. & Med. Ctr. v County Wide Ins. Co. (2005 NY Slip Op 10114)
December 27, 2005
The court considered an action to recover no-fault medical payments under an insurance contract. The main issue was whether the plaintiffs were entitled to summary judgment on their first and second causes of action, and whether the defendant's cross motion for summary judgment dismissing those actions should be granted. The holding was that the Supreme Court correctly granted the defendant insurer's cross motion for summary judgment dismissing the first cause of action, but erred in granting summary judgment dismissing the second cause of action. The second cause of action was reinstated, as numerous questions of fact existed as to how the claim was processed and whether it should be paid by a workers' compensation carrier. Neither party demonstrated its prima facie entitlement to judgment as a matter of law, and the remaining contentions were deemed without merit.