No-Fault Case Law

The court was considering an appeal in a case involving plaintiff health care provider's claim for first-party no-fault benefits for medical services rendered to its assignor. The main issue was whether the denial of plaintiff's claim on the ground that plaintiff's assignor failed to appear for examinations under oath (EUOs) was valid. The court held that the plaintiff was entitled to summary judgment, as the defendant failed to establish in the first instance that the insurance policy contained an endorsement authorizing EUOs, and therefore, plaintiff's failure to appear for EUOs cannot be a basis for denial of the claim. The decision was reversed, and the matter was remanded for the calculation of statutory interest and attorney's fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

The court considered the defendant's motion to disqualify the plaintiff's law firm, Israel, Israel & Purdy, LLP, from representing the plaintiff on the grounds that the law firm had established a joint business venture with various no-fault medical providers. The defendant argued that the law firm's role in taking over billing functions for the medical providers would require the firm to testify and substantiate, making them an advocate and a witness in the same proceeding. The main issue decided was whether there was a violation of the Code of Professional Responsibility, DR5-102, and if disqualification of the law firm was warranted. The court held that the defendant's motion was without merit as there was no showing that the trial attorney would be called as a necessary witness or that disqualification was necessary. The court also granted the plaintiff's cross-motion for sanctions against the defendant's attorneys in the amount of $500.00 for filing a frivolous motion.

The Court considered that Plaintiff seeks to recover first-party no-fault insurance benefits for medical services rendered to its assignors who were injured in an automobile accident. Plaintiff made a prima facie showing that defendant failed to pay or deny the claims within 30 days after receiving plaintiff's demands and that payment of plaintiff's claims was overdue. The sworn statement of plaintiff's billing manager that the claim forms were mailed to defendant on the date each was signed was uncontradicted on this record. The main issue decided was whether the plaintiff's unopposed motion for summary judgment should have been granted, and the Court held that since Plaintiff made a prima facie showing that defendant failed to pay or deny the claims within 30 days after receiving the demands and that payment of plaintiff's claims was overdue, the Plaintiff's unopposed motion for summary judgment should have been granted.

The case involves a first-party benefits action after a motor vehicle accident in which the plaintiff, Dr. Hellander, provided diagnostic testing to the injured party, Mr. Espinoza. State Farm Insurance Company denied payment for the claim, alleging lack of standing of the plaintiff and lack of medical necessity of the diagnostic testing. At trial, the plaintiff provided evidence of the assignor's signature and the statutory forms of proof of claim and the amount of the loss. State Farm objected to the assignment of benefits based on the lack of authentication of the signature on the form, and also argued that spinal ultrasound testing was not medically necessary. The court held that the plaintiff had established a prima facie case, and that the burden of proof shifted to State Farm on the claim of lack of medical necessity. The court found that State Farm's expert's testimony was equivocal and did not meet the burden of proof necessary to establish that the testing was not medically necessary, and therefore the judgment was rendered for the plaintiff.

The case New York & Presbyt. Hosp. v Allstate Ins. Co. involves an action to recover no-fault medical payments where the plaintiff alleged that the defendant failed to issue a denial of the claim within 30 days of its receipt. The first cause of action was for a claim submitted as the assignee of Adrian Leaf, and the second cause of action was for a claim submitted as the assignee of Noemi Gomez. The plaintiff was granted summary judgment on both causes of action by the Supreme Court, Nassau County. However, the Appellate Division, Second Department reversed the order, with costs, and denied the motion. The court decided that the plaintiff was entitled to judgment on their first cause of action as there were no timely denials of the claims. However, the coverage limits of the policy could be a defense, and there were issues of fact as to whether the coverage limits were exhausted. For the second cause of action, the defendant submitted evidence that the disputed claim was the second of two successive claims for the same services, and the first was properly denied. Therefore, failure to issue a timely denial of the second of these two successive but identical claims would not warrant granting the plaintiff judgment.

The court considered whether the plaintiff was entitled to recover unpaid no-fault insurance benefits. The main issues were whether the plaintiff was intoxicated at the time of the accident within the meaning of the no-fault insurance law, and whether his intoxication was a proximate cause of the accident. The court held that there were issues of fact regarding the plaintiff's intoxication that precluded granting the defendant's cross motion for summary judgment dismissing the complaint. As a result, the court modified the order to deny the cross motion and reinstate the complaint, and affirmed with costs payable to the plaintiff. The plaintiff's remaining contentions were deemed without merit by the court.

The relevant facts of the case were that the plaintiff health care providers sought to recover first-party no-fault benefits for medical services provided to their assignor. They established a prima facie entitlement to summary judgment by submitting the statutory claim form and showing that the defendant failed to pay or deny the claim within the 30-day statutory period. The main issue decided was whether the defendant was precluded from raising most defenses due to its failure to timely deny the claim, and whether the defendant could assert the defense that the collision was in furtherance of an insurance fraud scheme. The holding of the case was that while the defendant was precluded from raising most defenses, it was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme. The court found that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, and therefore the plaintiffs' motion for summary judgment was properly denied.

The relevant facts that the court considered in this case were that a health care provider, S & M Supply Inc., was seeking to recover no-fault benefits for medical services rendered to its assignor, Michael Monsignal. The issue before the court was whether the health care provider had established a prima facie entitlement to summary judgment, and whether the insurance company, State Farm Mutual Automobile Insurance Company, was precluded from raising defenses due to failure to pay or deny the claim within the 30-day claim determination period. The holding of the court was that the health care provider had established a prima facie entitlement to summary judgment, and the insurance company was precluded from most defenses due to the untimely denial of the claim. However, the insurance company was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and since they demonstrated the existence of a triable issue of fact as to lack of coverage, the plaintiff's motion for summary judgment was properly denied.

Relevant facts considered by the court include an automobile accident that occurred on February 20, 1999, injuries sustained by the respondent Stephanie Drasgow, and a claim for additional personal injury protection (APIP) benefits. The main issues decided in this case included whether the notice of the claim for APIP benefits was given within the 90 days after the accident, as required by petitioner's policy, and whether it was impossible for respondent to provide notice due to specific circumstances beyond her control. The holding of the case was that the Supreme Court properly granted the petition seeking to vacate the arbitration award directing the petitioner to pay additional personal injury protection (APIP) benefits to the respondent. The court concluded that there was no rational basis for the arbitrator's finding that it was impossible for the respondent to provide notice within the 90-day period because of circumstances beyond her control. Two of the judges dissented and argued that the arbitrator's finding was based upon the weighing of factual matters and the record supports that determination. They requested that the order be reversed, petitioner's petition to be denied, and respondent's petition be granted, confirming the arbitrator's award.

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.