No-Fault Case Law

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.

The court considered the submissions by both the plaintiff and defendant, including the affidavit of the defendant's special investigator supported by examinations under oath taken of the plaintiff's assignor and other persons involved in the accident. The main issue decided was whether the defendant's submissions raised a triable issue of fact as to whether the collision was part of a fraudulent insurance scheme. The holding of the court was that the defendant's submissions were sufficient to raise a triable issue of fact, and therefore the plaintiff's motion for summary judgment was properly denied.

The main issue in this case was whether the plaintiff, a healthcare provider, was entitled to summary judgment on its claim for first-party no-fault benefits for services rendered to its assignor. The plaintiff had submitted a complete proof of claim to the defendant, an insurance company, and the defendant failed to pay or deny the claim within the prescribed 30-day period. The court found that the defendant's requests for examinations under oath did not toll the 30-day period, as the insurance regulations in effect at the time did not require a claimant to appear for an examination under oath. The court held that the defendant was precluded from asserting most defenses due to the untimely denial of the claims, but was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme. The defendant's special investigator submitted an affidavit demonstrating a "founded belief that the alleged injuries do not arise out of an insured incident," and the court found that this was sufficient to demonstrate the existence of a triable issue of fact. Therefore, the plaintiff's motion for summary judgment was properly denied by the court. Ultimately, the holding of the case was that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, and as a result, the plaintiff's motion for summary judgment was properly denied.

The court considered the claim by S & M Supply Inc. to recover first-party no-fault benefits for medical equipment provided to its assignors. S & M Supply Inc. established its entitlement to summary judgment by submitting properly executed claim forms. The main issue decided was that the defendant, State Farm Mutual Automobile Insurance Company, failed to pay or deny the claims within 30 days of receipt, which precluded its defense based on the assignors' failures to attend examinations under oath. However, the preclusion rule was found to be inapplicable to a claim that the underlying traffic incident was deliberate and staged as part of a scheme to defraud, which would constitute a complete defense to the action. The holding of the case was that the defendant's submissions sufficed to demonstrate a "founded belief that the alleged injury did not arise out of an insured incident," which supported their defense.

The court considered the timeliness of the defendant insurer's denial of the plaintiff, King's Medical Supply Inc., first-party no-fault benefits claim and the evidentiary support for the denial, including the necessity for the supplies provided by the medical equipment supplier to the injured party. The main issue decided was whether defendant's denial of the claim was timely and whether there was sufficient evidentiary support for the denial. The holding of the case was that the plaintiff's motion for summary judgment was granted in all respects based on the court's finding that the defendant's denial was untimely and without evidentiary support, and therefore, plaintiff was entitled to first-party no-fault benefits, attorney's fees, and costs.

The court considered the circumstances of an accident in which a pedestrian was struck by a vehicle insured by Country-wide Insurance Company, and the subsequent actions of the insurance company in response to settlement offers made by the injured party. The main issue was whether Country-wide Insurance Company acted in bad faith by failing to accept the injured party's settlement offer. The court held that to establish a prima facie case of bad faith refusal to settle, a plaintiff must demonstrate that the insurance carrier engaged in a pattern of behavior evincing a conscious or knowing indifference to the probability that an insured would be held personally accountable for a large judgment if a settlement offer within the policy limits were not accepted. The court determined that Country-wide's conduct in this matter was not a model of diligence but held that the limiting timeframe and other factors weighed against the injured party's bad faith claim, and granted the insurance company's motion for summary judgment dismissing the complaint.

The court considered a motion for summary judgment by the plaintiffs for statutory interest and attorneys' fees on no-fault claims that the defendant allegedly paid late. The main issue was whether the plaintiffs could "bundle" a series of de minimis actions that are related only by the defendant's common response to the claims underlying those actions. Additionally, the court considered whether it should grant summary judgment because the defendant had not opposed the motion and made no motion to sever. The court held that the action was based on a series of de minimis claims that may not be joined under CPLR 1002, and denied the motion for summary judgment, but gave the plaintiff leave to move to sever the plaintiffs and to renew the motion for summary judgment as to those plaintiffs.

The claimant was injured in a car crash and was denied no-fault benefits by her insurance company. This claimant was seeking supplementary uninsured motorist (SUM) benefits from their insurance company. After a lengthy series of doctor consultations, she eventually discovered she had severe injuries and pursued the SUM claim. The Supreme Court ruled in favor of the insurance company, determining the claimant did not provide timely notice of her claim. The appellate court disagreed, stating that the claimant acted with due diligence in ascertaining her claim, and the delay was reasonable. As a result, the court reversed the decision in favor of the insurance company, granting the application for a permanent stay of arbitration.