No-Fault Case Law

The New York Supreme Court, Appellate Division, Second Department reversed an order denying a motion to vacate a judgment in a case brought by New York University Hospital Tisch Institute to recover unpaid no-fault benefits from Merchants Mutual Insurance Co. The court ruled that the denial of the motion was an unwise exercise of discretion. The defendant's default was found to be reasonable due to an inexperienced claims adjuster's belief that advising opposing counsel that no-fault benefits had been exhausted would be sufficient. The court also found that the defendant demonstrated a reasonable excuse for the default and a meritorious defense, and that there was a lack of prejudice to the plaintiff. Therefore, the judgment entered upon the defendant's default was vacated, and the case was remitted for further proceedings.

The court considered whether the plaintiffs were entitled to recover no-fault insurance medical payments. Mount Sinai Hospital demonstrated that it submitted the required documents to recover payment for medical services, but Zurich American Insurance Company neither paid nor denied the claims. However, an insurer is not required to pay a claim where the policy limits have been exhausted. In opposition to Mount Sinai's motion, Zurich demonstrated that there were issues of fact as to whether it exhausted the coverage limits of the policy by other "no-fault" payments and whether such payments were in compliance with 11 NYCRR 65.15. The main issue decided was whether Mount Sinai and Wyckoff Heights Medical Center, as assignee of Juan Picardo, were entitled to judgment as a matter of law on their first and third cause of actions. The holding of the case was that Mount Sinai's motion for summary judgment on the first cause of action was denied, while Wyckoff Heights Medical Center was granted summary judgment on the third cause of action.

The court considered whether a defendant was required to attempt to conduct a deposition before moving for preclusion in a no-fault first party benefits case. The plaintiff did not dispute that it did not attend the deposition session as ordered, but argued that the defendant should have made a specific statement on the record of an attempted examination before trial in order to secure preclusion. The court held that the defendant was not required to undergo the expense and trouble of arranging for a deposition before moving for preclusion. Therefore, the defendant's motion was granted, and full preclusion was accorded against the plaintiff, resulting in the dismissal of the complaint.

The relevant facts in this case were that the plaintiff, Amaze Medical Supply Inc., sought to recover first-party no-fault benefits for medical supplies furnished to its assignor. The plaintiff established a prima facie entitlement to summary judgment by showing that it submitted a claim, setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The defendant, GEICO Insurance, timely denied the claims but failed to submit proof in admissible form in opposition to the plaintiff's motion to rebut the prima facie showing. The defendant's submission, an unsworn peer review report, was deemed insufficient to warrant the denial of the plaintiff's motion for summary judgment. Therefore, the appellate court reversed the order denying the plaintiff's motion for summary judgment, granted the motion, and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106(a) and the regulations promulgated thereunder.

The court considered the fact that the plaintiff had submitted a claim for first-party no-fault benefits for medical services and that payment was overdue. The main issue decided was whether the defendant's defense of insurance fraud could be raised, despite the untimely denial of the claim. The court held that the defendant was precluded from raising most defenses due to the untimely denial of the claim, but was not precluded from asserting the defense of insurance fraud. The court found that the affidavit submitted by the defendant's special investigator was sufficient to demonstrate the existence of a triable issue of fact, and therefore the plaintiff's motion for summary judgment was properly denied.

The relevant facts considered by the court in this case include the denial of claims for medical services by an insurance company, the timing of the denials, and the issue of standing for the plaintiff to bring the action. The main issues decided by the court were whether the insurance company's denials of the claims were timely, the propriety of denial based on pending investigation, the authentication of assignment of benefits, and the standing of the plaintiff to bring the action. The holding of the case was that defendant's defenses were waived due to untimely denials and that further discovery was necessary to determine the plaintiff's standing to bring the action. The court extended the discovery period for this purpose and granted plaintiff summary judgment on claims that had not already been paid if they were found to have standing.

The court considered whether the plaintiff, a healthcare provider, was entitled to summary judgment to recover $2,670.40 in assigned first-party no-fault benefits for medical services rendered to its assignor. The main issue was whether the plaintiff had demonstrated a prima facie case for entitlement to this sum. The court held that the plaintiff had established a prima facie entitlement to summary judgment by proving that it submitted a claim form, and that payment of no-fault benefits was overdue, precluding the defendant from interposing most defenses to the action. The defendant was not precluded from asserting the defense that the alleged injuries did not arise out of a covered accident, which would constitute a complete defense to the action, but the defendant failed to sufficiently raise a triable issue of fraud in alleging staged-accident fraud. Therefore, the order granting plaintiff's motion for summary judgment was affirmed.

The court considered the facts that plaintiff health care provider submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that the defendant insurance company failed to pay or deny the claim within the 30-day prescribed period. The main issue decided was whether the defendant was precluded from raising defenses due to the untimely denial of the claim, and whether the defendant's assertion that the accident was fraudulent was supported by admissible evidence. The holding was that the plaintiff's motion for summary judgment was granted in the principal sum of $1,791.73, and the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder. The court also ruled that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, but failed to submit proof in admissible form to rebut the plaintiff's prima facie showing.

The relevant facts in the case involved six motions consolidated into a single decision. The insurer sought to strike the plaintiff's complaint or preclude the plaintiff from testifying at trial due to the plaintiff's failure to respond to discovery notices. The central issue was the permissibility of discovery in litigation for no-fault first-party benefits, and the courts needed to define what constitutes legitimate discovery requests in such cases. The holding of the court was that the request for discovery must be substantiated by a timely denial of the claim form (NF-10) or a timely demand for verification (NF-3 or NF-5) in a no-fault action, and failure to include proof of these forms in a discovery motion would lead to the motion being denied. The court also emphasized that discovery demands must be specific, relevant, and not burdensome or oppressive, and they must adhere to the rules and procedures set forth by law. The court denied each of the six motions based on these principles.

The main issue in this case was whether the defendant, Lumbermans Mutual Insurance Co., had timely denied the claim for no-fault benefits and whether their basis for the denial was sufficient under the Insurance Law. The court found that the insurance company's denial was not timely, as it was sent more than thirty days after the receipt of the claim, and they had failed to provide competent evidence of the timely mailing of the request for verification or the denial. The court also found that the language used by the insurance company in the denial was not specific enough to effectively deny the claim based on fraud. As a result, the court granted the plaintiff, Delta Diagnostic Radiology, P.C., summary judgment and denied the defendant's motion for partial summary judgment. The court also denied the defendant's motion to compel discovery.