No-Fault Case Law

Facts: The plaintiff, a no-fault insurance carrier, had commenced action pursuant to Insurance Law § 5106 (c) for de novo adjudication of a dispute regarding its denial of the defendant's claim for no-fault insurance benefits for medical services rendered to its assignor. After defendant failed to timely appear or answer the complaint in this action, the Supreme Court granted the plaintiff's unopposed motion for leave to enter a default judgment. The court subsequently issued a default judgment dated July 31, 2017. Issues: Whether the defendant would be able to demonstrate a reasonable excuse for its default in order to vacate it under CPLR 5015 (a) (1), and if there was a potentially meritorious defense to the action. Holding: The Court held that the defendant did demonstrate a reasonable excuse for its default and a potentially meritorious defense to the action under CPLR 5015 (a) (1). The court pointed out the defendant setting forth evidence that it had previously prevailed before an arbitrator on the merits of its defense as the main reason for granting the defendant's motion pursuant to CPLR 5015 (a) (1) to vacate its default in answering the complaint.

The main issue in this case was the court's consideration of reasonable attorneys' fees in connection with securing payment of an overdue claim for no-fault benefits. The court held that the lower court erred in calculating the award of attorneys' fees, as it failed to consider the regulation applicable to an appeal of a master arbitration award, and instead applied the regulation applicable to attorneys' fees awards at an initial arbitration. Pursuant to Insurance Law § 5106 (a), if a valid claim for no-fault benefits is overdue, the claimant is entitled to recover reasonable attorney's fees, subject to limitations promulgated by the superintendent in regulations. In this case, as the matter was an appeal from a master arbitration award, the court remanded the matter for a calculation of fees in accordance with the proper regulation. Additionally, the court rejected the appellant's claims for further fees for the underlying arbitration, as they were not preserved.

The relevant facts considered by the court in the case of Faith Acupuncture, P.C. v Government Empls. Ins. Co. were that plaintiff commenced the action to recover assigned first-party no-fault benefits on May 10, 2011, and that the defendant served the plaintiff's attorney with a 90-day written demand pursuant to CPLR 3216. The plaintiff filed a notice of trial more than 90 days after receiving the demand, and defendant moved to dismiss the complaint on the grounds that plaintiff had not been served with a notice of trial and that there was a delay in the proceedings. The main issue decided by the court was whether the plaintiff had a justifiable excuse for the delay and whether they had a meritorious cause of action. The court held that since the affirmation submitted by plaintiff's attorney did not provide a detailed and credible explanation of the law office failure that had caused the delay, plaintiff's claim of law office failure did not rise to the level of a justifiable excuse. Therefore, the court granted the defendant's motion to dismiss the complaint pursuant to CPLR 3216.

The court considered whether the defendant's motion for summary judgment dismissing the complaint should be granted in this action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs) and if the denial of claim forms were timely mailed. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint should be granted, as they demonstrated that the plaintiff's assignor had failed to comply with a condition precedent to coverage by not appearing for the scheduled IMEs, and that the denial of the claim was timely. Therefore, the order was reversed and the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the petition of Hereford Insurance Company to vacate a master arbitrator's award, which was granted by the Civil Court of the City of New York but then reversed on appeal. The main issue decided was whether the Civil Court erred in vacating the master arbitrator's no-fault award on the ground that it was contrary to a subsequent order rendered by the Supreme Court, New York County. The holding of the court was that the preclusive effect of a pre-arbitration judicial decision may be sufficient to vacate an arbitral award, but a post-arbitration judicial determination concerning the insurer's liability is not one of the limited grounds for vacating an arbitration award. The court found Hereford's alternative grounds for vacating the award to be unavailing, and therefore denied the petition to vacate the award and reinstated the master arbitrator's decision.

The court considered the defendant's motion for summary judgement based on the plaintiff's failure to appear for an examination under oath and the defense of policy exhaustion. The plaintiff cross-moved for summary judgment and to dismiss defendant's affirmative defenses. The court held that the defendant failed to establish entitlement to judgment as a matter of law on the issues of proper mailing of the examination under oath request, the nonappearance of the plaintiff's assignor at the examinations under oath, and the timeliness of its denial. The court also held that the defendant failed to establish that its exhaustion of policy defense was based on proper priority of payment of claims. The court ultimately denied all of the motions before the court, except for granting the plaintiff's cross-motion to the extent that it had been established that the bills at issue were mailed to and received by the defendant.

The court considered an action pursuant to Insurance Law § 5106 (c) for a de novo determination of the defendant's claims for no-fault insurance benefits due to a motor vehicle accident. The plaintiff appealed a master arbitrator's award of benefits to the defendant in the principal sum of $11,352.46, plus interest and attorney's fees. The plaintiff insurer claimed that the amount of the benefits sought by the defendant was not in accordance with the workers' compensation fee schedule and that the spinal fusion surgery performed on the claimant was not medically necessary. The main issue decided by the court was whether the plaintiff was obligated to pay the defendant no-fault benefits relating to the surgery, and whether the benefits sought by the defendant were in accordance with the workers' compensation fee schedule. The holding of the court was that the plaintiff had failed to demonstrate that the surgery performed on the claimant was not medically necessary, but the plaintiff had established its prima facie entitlement to judgment as a matter of law that the benefits sought by the defendant were not in accordance with the workers' compensation fee schedule. As such, the court modified the order by granting summary judgment to that effect.

The relevant facts in the case are that the defendant, an insurance company, filed a motion seeking an order to grant it summary judgment and dismissal of the action. The insurance company avers that it timely denied the plaintiff's claims for medical services under a no-fault insurance policy on grounds that the assignor failed to appear for two Independent Medical Examinations (IMEs). The plaintiff opposed the defendant's motion, asserting that the evidence presented by the defendant regarding the assignor’s appearance at the IMEs was conclusory. The main issue decided by the court was whether the defendant was entitled to summary judgment and dismissal of the action based on the plaintiff's failure to comply with the conditions precedent for payment of no-fault benefits. The court granted the defendant's motion in part and denied the plaintiff's cross-motion. The holding of the case was that the defendant was entitled to summary judgment based on the plaintiff's failure to comply with the technical requirements of the no-fault law, which are preconditions for payment to a medical provider.

The relevant facts the court considered were that the plaintiff, Gentlecare Ambulatory Anesthesia Services, was seeking to recover assigned first-party no-fault benefits from the defendant, GEICO Ins. Co. The defendant had moved for summary judgment dismissing the complaint on the basis that the plaintiff had failed to appear for duly scheduled examinations under oath. The main issue decided was whether the plaintiff's failure to appear for scheduled examinations under oath warranted the dismissal of their complaint. The court held that the plaintiff's failure to appear for the examinations under oath justified the granting of the defendant's motion for summary judgment, thus dismissing the complaint.

The court considered an appeal from an order of the Civil Court which granted the defendant's motion for summary judgment dismissing the complaint in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The court reversed the order, with $30 costs, and denied the defendant's motion for summary judgment dismissing the complaint. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was denied, and the order of the Civil Court was reversed.