No-Fault Case Law

The court considered the plaintiff’s motion to strike the defendant’s seventh, eighth, and tenth affirmative defenses on the ground that they were not pleaded with the specificity required by CPLR 3016(b) in an action to recover first-party no-fault benefits under Insurance Law § 5101. The defendant State Farm Mutual Automobile Insurance Company denied a claim for first-party no-fault benefits in the amount of $757.00 for medical supplies provided to its assignor Edme Aenor in connection with injuries arising out of a September 2, 2002 motor vehicle accident. Defendant’s affirmative defenses asserted fraudulent conduct, fraudulently misrepresented costs, and that the medical supplies for which reimbursement is sought were not related to the accident. The court granted in part and denied in part plaintiff’s motion to strike, specifically striking defendant’s seventh and eighth affirmative defenses and that portion of defendant’s tenth affirmative defense alleging that "the medical supplies for which reimbursement is sought were never actually provided". The court held that these defenses were being stricken because of defendant’s admitted failure to pay or reject the claims within 30 days of receipt, but declined to strike the portion of defendant’s tenth affirmative defense alleging that "the medical supplies for which reimbursement is sought were not related to the accident."

The court considered a case where health care providers were seeking assigned no-fault benefits from an insurance company, State Farm Mutual Automobile Insurance Company. The main issue was whether the health care providers were entitled to summary judgment for assigned no-fault benefits, as well as whether the insurance company was precluded from asserting the defense of an insurance fraud scheme due to an untimely denial of the claims. The court held that the health care providers established their entitlement to summary judgment for assigned no-fault benefits, as the insurance company failed to pay or deny the claims within the prescribed 30-day period. However, the insurance company was not precluded from asserting the defense of an insurance fraud scheme, as the affidavit submitted by their special investigator demonstrated a "founded belief that the alleged injuries do not arise out of an insured incident." Therefore, the plaintiffs' motion for summary judgment was properly denied.

The main issue in this case was whether the plaintiff was entitled to summary judgment in its favor. The court considered the evidence presented by the plaintiff, which consisted of an affirmation of counsel, an unverified complaint, and an affidavit from "Ernest Horowitz MD," who stated that the assertions in his counsel's affirmation were true and correct. However, the court did not accept the attempted incorporation by reference of the factual allegations contained in the counsel's affirmation. The court also noted that the No-Fault Verification of Treatment furnished by the plaintiff's counsel to the court differed from what was apparently sent to the defendant upon submission of the claim. As a result, the court denied the plaintiff's motion seeking summary judgment and awarded costs to the defendant. The holding of the case was that the plaintiff's motion for summary judgment was denied, and costs were awarded to the defendant.

The main issue in this case was whether the award of an arbitrator denying the disputed billing for MRIs, based on lack of documented medical necessity, was arbitrary, capricious, or incorrect as a matter of law. The court considered the fact that the insurer failed to deny the claim within the prescribed thirty-day period, as well as the legal precedent regarding the burden of proof in first-party no-fault claims. The court held that the insurer is precluded from raising any defense other than lack of coverage when it fails to comply with the rule requiring it to deny a claim within thirty days. Therefore, the court vacated the decision of the Master Arbitrator and found for the petitioner in the amount of $1,791.73, with statutory interest and fees as established in section 5106(a) of the Insurance Law.

The court considered whether an insurer was required to pay out a claim for a first-party benefit pursuant to New York's No-Fault Insurance Law within the statutory 30-day period following submission of the claim. The insurer argued that it was not subject to the provisions of the law because the person allegedly injured in the motor vehicle accident did not submit to several requests for an examination under oath, and also that the accident was staged. The court found that Regulation 68-A applied to claims filed after its effective date, and therefore denied the plaintiff's motion for summary judgment. Additionally, the court found that the insurer's argument that the plaintiff's assignor was not a covered person because of alleged fraud was without merit due to a lack of evidence. Therefore, the plaintiff's motion for summary judgment was denied.

The court considered the failure of the defendant to pay or deny claims for medical services rendered to Kathleen Marsh after an automobile accident. The main issues decided were whether the defendant had a reasonable excuse for its delay in answering the complaint and whether the defendant had a meritorious defense in claiming that the treatments rendered by the plaintiffs were not medically necessary. The court held that the defendant did not have a reasonable excuse for its delay in answering and did not have a meritorious defense, as the defendant was precluded from denying the claims due to the lack of a timely denial, and therefore the motion to vacate the default and set aside the judgment was denied.

The Civil Court of the City of New York, Kings County, decided the case of CKC Chiropractic v Republic W. Ins. Co. The plaintiff sought to recover first-party benefits under New York’s No-Fault Law and filed a motion for summary judgment against the defendant. The defendant argued that they did not have to pay the claim because the plaintiff was not currently registered with the New York State Department of Education. The main issue before the court was whether a health care provider who is registered with the New York State Department of Education at the time services are provided may recover the value of those services under New York's No-Fault Insurance Law if the provider is no longer registered at the time payment for those services is sought. The court held that a medical provider may be reimbursed for services rendered while he or she was registered to perform such services under the No-Fault Law, even if the provider subsequently becomes unregistered. As a result, the plaintiff’s motion for summary judgment was granted and the defendant's cross-motion was denied.

The court considered the fact that the plaintiff, a health care provider, submitted proof that it had mailed statutory claim forms to the defendant, that the defendant received them, and that the defendant did not pay or deny the claims within the 30-day statutory period. The main issue decided was whether the defendant's untimely denial of benefits precluded them from asserting the defense that the alleged injuries did not arise from a covered accident. The holding of the court was that the plaintiff's motion for summary judgment was granted, and the case was remanded for the calculation of statutory interest and attorney's fees pursuant to Insurance Law. The court also determined that the affidavit of defendant's attorney, who had no personal knowledge of the facts and made bare and conclusory allegations of fraud, was insufficient to raise a triable issue of fact.

The main facts considered in the case included a motor vehicle accident claim in which the petitioner sought reimbursement pursuant to New York state law for loss transfer compulsory arbitration for no-fault payments. The main issue was the application of the three year statute of limitations, which was imposed by the arbitrator from the date of the accident. Arbitration decisions were vacated repeatedly due to erroneous application of the statute of limitations. The court held that the compulsorily arbitration decision must have evidentiary support and cannot be arbitrary and capricious. The court ultimately vacated the arbitration award and set the motion for sanctions against the responsible company down for a hearing regarding evidence of attorney's fees expended.

The court considered the case of King's Medical Supply, Inc. seeking to recover no-fault benefits for medical supplies provided to its assignor from Hereford Insurance Company. Plaintiff moved for summary judgment in the amount of $980, but the motion was denied by the court. The main issue decided was whether the plaintiff's billing manager had to allege in his supporting affidavit that he had personal knowledge that the equipment was furnished to plaintiff's assignor. The court found that the exhibits submitted by the plaintiff's billing manager established that the supplies were furnished to the assignor but also found that a triable issue of fact existed regarding the timeliness of the defendant's denial of the claim. Therefore, the court affirmed the order denying the plaintiff's motion for summary judgment.