No-Fault Case Law

The main issues considered in this case were whether the appellant, David Bett, was entitled to supplementary uninsured motorist (SUM) benefits under his policy from New York Central Mutual Fire Insurance Company. The court also had to decide whether the recorded statement given by Bett to the company's independent insurance adjusting firm soon after the accident was sufficient notice to the insurer of the claim for SUM benefits. The court's decision was that Bett failed to give timely notice of his SUM claim to the insurer, which was a condition of SUM coverage in his policy. The court acknowledged that Bett had given a recorded statement to the insurance company a week after the accident, but still held that the notice of his SUM claim was untimely. As a result, the petition for a permanent stay of arbitration was granted, denying Bett SUM coverage under his policy.

The court considered the fact that the plaintiff sought to recover first-party no-fault benefits for medical services rendered to their assignor, as well as statutory interest and attorney's fees, and that the defendant failed to pay or deny the claims within the statutory 30-day period as required by Insurance Law section 5106(a). The main issue decided was whether the plaintiff was entitled to summary judgment, and the court held that the plaintiff's motion for summary judgment was granted in its entirety, with a judgment in favor of the plaintiffs in the amount of $14,628.06, together with appropriate statutory interest and attorneys' fees. The court also found that the defendant failed to comply with follow-up procedures and timetables for verification, and failed to submit evidentiary proof to establish that the benefits sought for medical supplies were not in conformity with the charges permissible under the workers' compensation fee schedule law, precluding the defendant from raising certain defenses in its opposition to the motion. The court did not consider the defendant's amended affirmation in opposition in rendering its decision and order, as the amended papers were not timely served upon the plaintiffs.

In this case, the court considered the motion for an order disqualifying the law firm representing the plaintiff in the proceeding. The defendant alleged that the law firm was in violation of the Code of Professional Responsibility as one of its members ought to be called as a witness in the proceeding. The facts of the case involved a medical services provider billing an insurance carrier under the state No-Fault Law, with the firm preparing and mailing bills on behalf of the provider. The defendant argued that a non-attorney member of the firm was necessary to establish a prima facie case. The main issue decided was whether the law firm should be disqualified based on this allegation. The court held that a clerk of the law firm employed in the mailroom, responsible for mailing the plaintiff's bills and proof of claim, would not cause the law firm to be disqualified from representing the plaintiff, simply because the clerk's testimony was necessary in establishing the elements of plaintiff's case. It was concluded that the rules governing lawyers' disqualification do not apply to non-lawyer employees of a law firm, and therefore, the law firm was not disqualified from representing the plaintiff. Thus, the court denied the defendant's motion for disqualification.

The main issue in Radiology Resource Network, P.C. v Fireman's Fund Insurance Company was whether the trial court erred in granting the defendant's motion to sever 68 assigned claims for no-fault insurance benefits into separate actions. The defendant argued that the claims arose from 68 different accidents, had been assigned to 68 different assignors, and raised unique legal and factual issues. The court decided that the trial court had not erred in granting the defendant's motion to sever the claims, as each claim raised unique legal and factual issues that would be better handled in separate actions. The court held that trying all 68 claims together would be unwieldy and would create a substantial risk of confusion for the trier of fact, and since the claims were likely to raise few common issues of law or fact, severing the claims was the best approach. The court drew upon a recent federal decision in a similar case, which stated that the assigned claims "arise out of distinct automobile accidents which led to different injuries to different individuals who underwent distinct medical services, payment for which was denied for varying reasons."

The court considered that plaintiff brought a suit to recover no-fault insurance coverage for medical services it provided to an individual who was insured with the defendant. Defendant moved for summary judgment, arguing that plaintiff's commencement of the action was premature due to plaintiff's failure to comply with defendant's verification requests. Plaintiff opposed defendant's motion, arguing that defendant's follow-up request was untimely. The court found that the defendant's verification requests were timely and proper according to the no-fault regulations. The court held that the plaintiff commenced the action prematurely as the defendant's verification requests were deemed timely and proper, and as the plaintiff did not respond to the timely and proper requests, the defendant was under no duty to issue a denial.

The main issue in the case was whether South Nassau Communities Hospital was entitled to recover unpaid benefits under the no-fault provisions of the Insurance Law. The court considered whether the hospital had made a prima facie showing of entitlement to summary judgment as a matter of law and whether there were any material issues of fact. The court ultimately denied the hospital's motion for summary judgment, finding that the hospital did not sustain its burden in demonstrating that the claims at issue were not subjects of previous billings that were resolved. Therefore, the court held that the hospital's papers failed to eliminate triable issues of fact, and it did not examine the adequacy of the defendant's papers in opposition to the motion.

The court considered the issue of whether petitioner State Farm Mutual Automobile Insurance Company submitted sufficient documentary proof to show that its no-fault payments to its subrogor were within the three year statute of limitations. The main issue decided was whether the arbitrator's dismissal of the claim as barred by the statute of limitations was arbitrary and capricious. The court held that State Farm did submit enough documentary proof to establish the dates of the initial payments and that the arbitrator's dismissal of the claim was not based on evidence. As a result, the court reversed the order denying State Farm's petition, granted the petition, vacated the arbitrator's award, and remanded the matter for arbitration.

The court considered the denial of first party benefits under New York's No-Fault Insurance Law for two assignors, Cadet and Gousse, who were injured in a motor vehicle accident. The main issue was whether the denials of benefits were received within the statutorily mandated 30 days after the receipt of the claims, as well as the sufficiency of the Examinations Under Oath (EUO) submitted by the defendant insurer. The holding of the court was that the denials were not received within the mandated 30 days, and the EUO submitted by the defendant insurer was not in a legally admissible form. Additionally, it was found that the insurer did not follow the procedures in seeking a second date for the EUO when Gousse failed to attend the first scheduled examination, therefore the 30-day statutory period was not tolled. The court granted the plaintiff's motion for summary judgment and awarded judgment in the amount of $4460 plus interest and attorney's fees.

The court considered the circumstances surrounding the denial of first-party benefits for an injury claim made by a medical provider to an insurance company. In this case, the injured party was in a car accident while driving the insured's vehicle, prompting the medical provider to submit claims for first-party benefits to the insurance company. The insurance company subsequently requested additional verification of the claims through an examination under oath (EUO) from the driver. However, the request was not received by the driver because the address used was incorrect. Additionally, the insurance company conducted EUOs with the passenger and the insured, then denied the claims for the passenger's treatments based on inconsistencies between the statements of the passenger and the insured. The main issues were whether the request for the EUO to the injured party's attorney was sufficient notification under New York's No-Fault Law and whether a denial of first-party benefits could be based on statements and suppositions made by someone lacking personal knowledge. The court held that the insurance company failed to make a legally valid request for verification within the prescribed time period and that the denial of benefits was untimely. Additionally, the court found that the denial of benefits based on unsubstantiated hypotheses and suppositions made by someone lacking personal knowledge was not sufficient, granting summary judgment for the plaintiff.

The court considered the insurer's obligation to provide a proper denial of claim uner New York regulations stating either to pay or deny a claim within 30 calendar days after proof of claim was received. The plaintiff submitted two claims to the insurer to recover no-fault medical payments but the defendant responded with a standard denial of claim which failed to include several important details. Including the name of the health services provider, the date and amount of the claims being denied, and the date it received those claims. The insurer contended it supplied the missing information after the 30-day period, however, the court found that the insurer's denial of claim was factually insufficient, conclusory, vague, and otherwise involves a defense that has no merit as a matter of law. The holding of the case was that the plaintiff's motion for summary judgment should have been granted on the ground that the April 14, 2003, denial of claim was fatally defective.