No-Fault Case Law

In Matter of Zurich American Insurance, an arbitrator failed to give preclusive effect to the jury's determination that a certain individual did not sustain any injuries due to a car accident, thereby awarding the insurance company a sum upon that determination. Hereford Insurance Company appealed the order, but the Supreme Court, Queens County upheld the petition and the denial of the cross petition. According to the appellate division, the decision to not give preclusive effect to the jury verdict was irrational and arbitrary. Furthermore, it was decided that an insurance company, as a subrogee, stands in place of the subrogor, such that two companies are in "privity," allowing the company to be bound by the prior judgment in a case to which it was not originally party to. The stay was affirmed and the court also ordered that Hereford reimburse Zurich for its legal fees.

The case of Andrew Carothers, M.D., P.C. v Progressive Ins. Co. involved determining whether an insurer could withhold payments for medical services provided by a professional corporation when there was a "willful and material failure to abide by" licensing and incorporation statutes. The main issue was whether a finding of fraud was required for the insurer to withhold payments to a medical service corporation improperly controlled by nonphysicians. The court ultimately held that there was no requirement for fraudulent intent or conduct "tantamount to fraud" for the insurer to withhold payments to a medical service corporation improperly controlled by nonphysicians. The court considered Andrew Carothers, M.D., P.C., a professional service corporation, which was formed by a radiologist in partnership with a nonphysician, leading to exorbitant fees being charged to the corporation for MRI equipment. The corporation was controlled by nonphysicians, and the quality of patient care was minimal, leading to no payment by insurance companies and eventual closure of the corporation.

The main issue in this case was whether the limits of the Florida insurance policy had been exhausted prior to the insurer's receipt of the claims, and whether the provider was entitled to be paid for its services pursuant to the workers' compensation fee schedule. The court found that the insurer failed to establish with admissible evidence that Florida law applied and that the policy limits had been exhausted. Therefore, the court held that the branches of the insurer's cross motion seeking summary judgment dismissing the third, fifth and seventh causes of action were denied. However, the evidence submitted by the insurer demonstrated that the provider was not entitled to be paid for certain services pursuant to the workers' compensation fee schedule, and the court found that the provider failed to raise a triable issue of fact in opposition. As a result, the branches of the provider's motion seeking summary judgment on the third, fifth and seventh causes of action were properly denied.

The court considered whether proper service of process had been completed in an action by a provider to recover assigned first-party no-fault benefits. The main issue was whether the affidavit of service demonstrated that the summons and complaint were served properly, as required by CPLR 3215. The court determined that proof of proper service is a prerequisite for the entry of a default judgment, and because the record did not demonstrate that an acknowledgment of receipt had been subscribed and affirmed by the defendant, the court reversed the judgment, vacated the order, denied the plaintiff's motion for the entry of a default judgment, granted the defendant's cross-motion to dismiss the action, and remitted the matter to the Civil Court for the entry of a judgment in favor of the defendant dismissing the action without prejudice. Therefore, the holding of the case was in favor of the defendant, and the action was dismissed without prejudice.

The court considered the appeal from an order of the Civil Court denying the defendant's motion seeking summary judgment dismissing part of the complaint and granting the plaintiff's cross-motion seeking summary judgment on that portion of the complaint. The main issue was whether the defendant's proof was sufficient to establish the proper mailing of examination under oath (EUO) scheduling letters and whether the plaintiff had submitted sufficient evidence to establish its entitlement to summary judgment. The court held that the defendant had established the proper mailing of the EUO scheduling letters, but failed to show that the plaintiff's claims were not timely denied. The court also held that the plaintiff failed to demonstrate its prima facie entitlement to summary judgment. As a result, the order was modified to deny the branch of the plaintiff's cross-motion seeking summary judgment on the claims as assignee of Rhonda Cobin.

The court considered a case where a provider was seeking to recover assigned first-party no-fault benefits from an insurance company. The case was settled in open court in 2011, but the insurance company did not pay the settlement amount. A judgment was subsequently entered in 2016. The main issue decided was whether the insurance company should be allowed to stay the accrual of no-fault statutory interest "between date of settlement and date of judgment." The court held that the branch of defendant's cross motion seeking to stay the accrual of no-fault statutory interest "between date of settlement and date of judgment" was denied, reversing the lower court's decision.

The court considered that this action by a provider to recover assigned first-party no-fault benefits was settled in open court on August 2, 2007, and defendant did not pay the settlement amount. A judgment was entered on June 21, 2016, pursuant to CPLR 5003-a. The main issue decided was that the Civil Court erred in staying interest from the date of the settlement of the action to August 23, 2016. The holding of the case was that the judgment was reversed, the branch of defendant's cross motion seeking to stay the accrual of no-fault statutory interest "between date of settlement and date of judgment" was vacated, and the matter was remitted to the Civil Court for the entry of a new judgment in accordance with the decision and order.

The main issue decided in this case was whether the master arbitrator's decision to affirm a lower arbitration award was rational or if it should be vacated. The court considered the fact that New York public policy strongly favors arbitration and that the scope of review of an arbitration decision is extremely limited. The court also considered the grounds set forth in the Civil Practice Law and Rules (CPLR) for vacating an arbitration award, and whether the master arbitrator exceeded his authority in making the award. The holding of the court was that the master arbitrator's award was not irrational and did not exceed his authority in affirming the lower arbitration award, so the petitioner's motion was denied and the master arbitrator's award was confirmed.

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.