No-Fault Case Law

The case of Shell v. Fireman's Fund Ins. Co. involved an appeal against the dismissal of a complaint for the insurance company regarding an unsatisfied judgment. The plaintiff, Nathaniel Shell, was involved in a motor vehicle accident with Raul L. Park, whose vehicle was insured by the defendant Fireman's Fund Ins. Co. The plaintiff obtained a judgment against Park and attempted to recover that judgment from the defendant's insurer. The defendant argued that their disclaimer letter was dispositive and that they were not liable because the plaintiff's insurer failed to give prompt notice. The court determined that the disclaimer letter was ineffective at disclaiming coverage of the plaintiff's claim as it pertained to the accident. The court held that since the disclaimer came over 12 months after the plaintiff notified the defendant of the claim, it was not timely and should have been granted summary judgment in favor of the plaintiffs. Therefore, the dismissal and granting of the insurance company's cross-motion for summary judgment was reversed and the plaintiffs were awarded summary judgment.

The New York and Presbyterian Hospital appealed from an order of the Supreme Court, Nassau County dated January 6, 2004 that granted the defendant's motion for summary judgment dismissing the first cause of action by the Hospital in an action to recover no-fault medical payments under an insurance contract. The Hospital's assignor, Marco Rizzi, received treatment for injuries related to an automobile accident covered under its policy with Government Employees Insurance Company (GEICO) from February 22, 2002, through April 3, 2002. GEICO had paid the Hospital $60,961.44, but the Hospital sought an additional $32,961.15. GEICO claimed to have sent the initial request for verification on April 22, 2002, and the parties disagreed as to when the claim was actually mailed. The Hospital raised a triable issue of fact as to whether the claim was mailed on May 9, 2002 and not received until May 13, 2002. The motion for summary judgment by GEICO should have been denied. The Court considered that the Hospital raised a triable issue of fact through the affidavit of Peter Kattis, a billing agent for the Hospital, stating that the Hospital's first claim was mailed on May 9, 2002, and not received until May 13, 2002. The main issue decided was whether GEICO's motion for summary judgment dismissing the Hospital's first cause of action on the ground that it had paid out all the money available under the no-fault portion of the policy should be granted. The holding of the case was that GEICO's motion for summary judgment dismissing the first cause of action should have been denied.

The relevant facts considered by the court in this case are that the plaintiffs initially submitted a Motion for Summary Judgment as providers of first party benefits under New York's No-Fault Insurance Law, which was denied due to insufficient support. The plaintiffs then submitted a second motion for summary judgment based on the same underlying claim, with new affidavits from treating physicians. The main issue decided by the court was whether a party may file a new Motion for Summary Judgment after an initial motion for the same relief on the same claim was denied. The court held that once a motion for summary judgment has been denied, subsequent motions seeking the same relief must be denied as res judicata, even if the original denial was based on a party's failure to come forward with evidentiary facts rather than on a full determination based on all relevant data. Therefore, the plaintiffs' Motion for Summary Judgment was denied as res judicata.

The relevant facts of the case included the plaintiff, a medical provider, initiating a claim for first party benefits under New York's No-Fault Insurance Law, and the defendant insurer denying the claim on the basis that the treatments provided were not medically necessary. The main issue decided by the court was the definition of "medical necessity" under the No-Fault statute, as it is not defined by the statute itself. The court considered several prior decisions attempting to define the term "medical necessity," including a definition adopted from the New Jersey courts and a modification of that definition based on pending legislation. Based on these decisions, the court held that an appropriate jury instruction on the definition of "medical necessity" is that for an expense to be considered medically necessary, the treatment, procedure, or service ordered by a qualified physician must be based on an objectively reasonable belief that it will assist in the patient's diagnosis and treatment and cannot be reasonably dispensed with. Such treatment, procedure, or service must be warranted by the circumstances as verified by a preponderance of credible and reliable evidence, and must be reasonable in light of the subjective and objective evidence of the patient's complaints.

The court considered whether the insurance carrier was entitled to disclaim coverage of plaintiff's late notice of the SUM claim in a declaratory judgment action. Plaintiff was rear-ended in an accident and filed a claim for no-fault benefits shortly after. After learning that the other driver, Bouyea, was underinsured and undergoing surgery for injuries from the accident, plaintiff notified State Farm and filed a lawsuit, but the insurance carrier disclaimed coverage based on the late notice of the SUM claim. The court ultimately held that the carrier must show prejudice before disclaiming coverage of a late notice of a SUM claim if the insured previously gave timely notice of the accident. Since the insured had given prompt notice of the accident, the carrier was required to demonstrate prejudice before disclaiming coverage. As a result, the court modified the decision of the Appellate Division and remitted the case to the trial court for the carrier to have an opportunity to demonstrate prejudice before further action could be taken.

The court considered the circumstances surrounding an automobile accident involving an employee of the URS Corporation, Mr. Wells, who sought workers' compensation, no-fault claim, disability benefits, and also filed a personal injury action. The main issue decided was whether Farmers New Century Insurance Company could seek reimbursement from National Union Fire Insurance Company, regarding the payment of first-party benefits to Mr. Wells. The court held that the dispute was not subject to mandatory arbitration pursuant to Workers Compensation Law 29 (1-a) and the loss transfer provisions of Insurance Law section 5105. The court granted National Union Fire Insurance Company's application to permanently stay the arbitration between the parties and denied Farmers New Century Insurance Company's cross-motion to dismiss the application.

The relevant facts of the case include a medical provider, T.S. Medical P.C., being denied no-fault benefits by an insurance company, Country Wide Insurance Co. After filing for arbitration, the arbitration award denied the petitioner's claim and was then reviewed by a Master Arbitrator, who upheld the lower arbitration award. The main issue at hand was whether the Master Arbitrator's decision should be vacated, as the award did not have a rational basis and did not comport with established principles of law. The court decided that the Master Arbitrator's award should be vacated, as it did not have a rational basis and did not correctly apply the law. Therefore, the court granted the petitioner's motion and vacated the Master Arbitrator's award.

The relevant facts considered by the court in this case involved a dispute over first-party no-fault benefits for medical services rendered to an assignor by plaintiff Daniel Kim's Acupuncture P.C. The main issue decided by the court was whether plaintiff Daniel Kim's Acupuncture P.C. was entitled to summary judgment, and whether the peer review report included by the defendant in its opposition was admissible. The holding of the case was that plaintiff Daniel Kim's Acupuncture P.C. established a prima facie entitlement to summary judgment and that the peer review report included by the defendant was unsworn and inadmissible. As a result, summary judgment was granted in favor of plaintiff Daniel Kim's Acupuncture P.C. The matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees. The appeal by the remaining appellants was dismissed.

The main issues decided in this case were whether the plaintiff was entitled to summary judgment in its action to recover assigned first-party no-fault benefits for medical supplies furnished its assignors, and whether the defendant's denial of the remaining claims was valid. The court held that the plaintiff was entitled to summary judgment as it established prima facie entitlement to summary judgment by proof that it submitted claim forms setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. Additionally, the court found that the defendant's denial of the remaining claims on the sole ground that plaintiff failed to produce the "initial narrative report[s] from the preparing physician" pursuant to a timely initial verification request was invalid. The matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees.

The relevant facts of the case are that King's Medical Supply Inc. was seeking to recover assigned first-party no-fault benefits from Kemper Auto & Home Ins. Co. King's Medical Supply Inc. was denied by Kemper Auto & Home Ins. Co. due to the eligible injured person's failure to attend the independent medical examinations as requested. However, Kemper Auto & Home Ins. Co. failed to follow up its initial verification request with a second IME request within the given time frame. Furthermore, Kemper Auto & Home Ins. Co. also asserted that King's Medical Supply Inc. failed to respond to two verification request letters regarding a separate claim. The main issues decided in the case were whether the denial form was effective to avoid preclusion and whether Kemper Auto & Home Ins. Co.'s proof of mailing sufficed to raise a triable issue of the timeliness of mailing. The court held that the denial form was ineffective to avoid preclusion as to all defenses to the $660 claim and that as to the $895 claim, Kemper Auto & Home Ins. Co.'s proof of mailing raised a triable issue of the timeliness of mailing. The court granted partial summary judgment in favor of King's Medical Supply Inc. in the principal sum of $660 and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees, and remanded for all further proceedings on the remaining claim.