No-Fault Case Law

The main issue that the court considered was whether the plaintiff's lost-wage claim was too speculative to be compensated under Insurance Law § 5102 (a) (2) due to an injury sustained from an automobile accident. The court held that both the statute and the regulation contemplated a degree of certainty in the calculation of lost wages and stated that they apply to reimburse a claimant for wages actually lost from employment engaged in at the time of the accident, and that those lost wages from that employment can be increased if the claimant can demonstrate a reasonable projection that his or her future earnings from said employment will increase. The court ultimately affirmed the lower court's decision by agreeing with the defendant's cross motion for summary judgment dismissing the plaintiff's lost-wage claim, as it was entirely speculative.

The case considered whether an insured met the criteria for notifying her insurer in a timely manner of her intention to file a supplemental underinsured motorist (SUM) claim. The appellant, Geraldine Celebucki, filed a claim for no-fault insurance benefits in July 1998 and later notified her insurer of her intent to file a SUM claim. However, the insurer disclaimed coverage for the SUM claim in February 2002 on the grounds that Celebucki had failed to notify them of her intent to seek such benefits until 3 ½ years after the accident. The court considered whether Celebucki provided notice of her SUM claim "as soon as practicable" and whether the notice was provided as required by her policy. The court held that timely written notice of the SUM claim was never provided and upheld the order that granted the insurer's application to stay arbitration.

The relevant facts considered in this legal case were that New York Hospital Medical Center of Queens sought to recover no-fault benefits, but Clarendon National Insurance Company failed to appear or answer the complaint. The main issue was whether the defendant had a reasonable excuse for their default and whether they had a meritorious defense. The court held that the defendant did not demonstrate a reasonable excuse for their default and therefore, the Supreme Court improvidently exercised its discretion in granting the defendant's motion to vacate the default judgment. The motion was denied and the judgment was reinstated by the court.

The court considered evidence submitted by the plaintiff, including assignments, proofs of claim, and denial of claim forms from the defendant as proof of mailing. The main issues included establishing whether the plaintiff had provided a prima facie case for summary judgment for recovery of no-fault benefits and determining if the defendant's belated denials could be deemed timely denied based on previously served blanket disclaimers. The holding of the case was that the plaintiff is entitled to summary judgment, as the defendant either failed to pay or deny the claims within thirty days of receipt, and the defendant was precluded from raising the defense of lack of medical necessity. The plaintiff was awarded the requested amount for no-fault benefits, with 2% interest per month, as well as attorneys' fees.

The court addressed ethical concerns raised by irregularities in papers submitted by the plaintiffs’ counsel, Edward Shapiro, in seven cases for assigned first-party no-fault benefits. The law firm submitted affirmations affirming that the plaintiff's "bills" were mailed on a specific date by "Edward Shapiro, Attorney at Law" to establish timely mailing, but there were signatures that were contradictory and misleading. While the plaintiffs argued that the office inadvertently failed to change its name from "Edward Shapiro, Attorney at Law" to "Edward Shapiro, P.C.," the court concluded that there was a deliberate attempt to mislead the court. The court held that the failure to sign the affirmations filed in each action nullified the motions, and the complaint in each action was dismissed without prejudice. The court found the actions of Mr. Shapiro and Mr. Moroff to be sanctionable under 22 NYCRR 130-1.2 for intent to deceive the court and their adversaries. The court assessed a total fine of $35,000 ($5,000 for each action) against counsel for the plaintiffs.

The court considered the fact that the plaintiff, a medical supply company, was seeking to recover no-fault benefits for medical supplies furnished to its assignor. The main issue decided was whether the plaintiff was entitled to summary judgment, as it had submitted statutory claim forms and payment of the benefits was overdue. The court held that the plaintiff had established prima facie entitlement to summary judgment and that the defendant had failed to establish the existence of a triable issue of fact. The holding of the case was that the plaintiff's motion for summary judgment was granted, and the matter was remanded for a calculation of statutory interest and an assessment of attorney's fees.

The court considered the denial of plaintiff's claim for $1,243.43 and an additional claim for $1,196.21 more than 30 days after it was submitted, and the insurer's right to an independent medical examination (IME) following a notice of claim. Plaintiff's motion for summary judgment was granted in part, awarding partial summary judgment in the principal sum of $1,243.43, but neither party was entitled to summary judgment on the claim of $1,196.21. The court found that the insurer had a right to an IME and had timely denied the claim on the ground that the plaintiff's assignor failed to comply with the IME request. Because of this, the insurer's motion for summary judgment should have been denied as well, as questions of fact existed regarding the medical necessity of the benefits provided. Ultimately, the holding of the case was that the plaintiff was entitled to partial summary judgment for the amount of $1,243.43, but no summary judgment was granted regarding the claim of $1,196.21. Additionally, because the insurer timely denied the $1,196.21 claim due to the assignor's failure to comply with the IME request, and the plaintiff failed to establish medical necessity, the plaintiff's motion for summary judgment was properly denied and the insurer's motion for summary judgment should have been denied as well.

The case involved a medical services company seeking to recover first-party no-fault benefits for medical services provided to an individual injured in a motor vehicle accident. The company moved for summary judgment in the amount of $4,366.28, and although the court granted partial summary judgment for the company in the amount of $2,176.30, it remanded the case for the calculation of statutory interest and assessment of attorney's fees. The main issue in the case was whether the medical services company had established its entitlement to summary judgment on its claims, which it did for three specific claims totaling $2,176.30. The court considered whether the company had submitted properly completed claim forms to the insurance company, and found that the company had established its entitlement to summary judgment for these specific claims. Therefore, the holding of the case was that the medical services company was granted partial summary judgment in the principal sum of $2,176.30, with the matter remanded to the lower court for further proceedings.

The court considered the fact that the defendant denied the plaintiff's claims for first-party no-fault benefits based on lack of medical necessity and the plaintiff's assignor's failure to appear for scheduled independent medical examinations. The main issue decided was whether the defendant effectively rebutted the presumption of medical necessity which ordinarily attaches to plaintiff's claim forms, and whether a triable issue of fact as to medical necessity was raised. The holding was that the defendant's proof of mailing IME scheduling letters demonstrated that they adhered to established business practices of proper mailing and that the plaintiff's failure to provide an acceptable excuse for its assignor's nonattendance warranted the granting of defendant's cross motion for summary judgment. The court also noted that if the issue of fees charged for the medical equipment had been raised, they would have entertained it.

The relevant facts in this case included an insurance company denying a health provider’s claim for $969.61 in assigned first-party no-fault benefits because the eligible injured person failed to appear for independent medical examinations before the provider filed its statutory claim forms. The main issue was whether the insurer's proof of the assignor's nonappearance established a defense to the action, and the court decided that the insurance regulations provide for independent medical examinations as part of the insurer's entitlement to "additional verification" following the insurer's receipt of a provider's statutory claim forms in order to determine the medical necessity of the health benefits provided to the injured person. The court held that because the examination was performed 7 days after the claim was submitted, the verification was untimely. Therefore, the ruling ordered that the portion of the order granting plaintiff summary judgment be deleted, and affirmed the order as modified.