Source: https://bruteforcelawyer.com/category/no-fault-mvaic/
Timestamp: 2019-04-20 12:47:26+00:00

Document:
In this regard, although the defendants stated, in their motion for summary judgment, that they first received the no-fault bill on May 7, 2009, or on May 9, 2010, the defendant did not establish that fact by submitting a copy of the bill [*2]received on one of those dates. Therefore, the defendants failed to submit evidence raising a triable issue of fact as to whether they timely denied the claim after issuing timely requests for additional verification (see 11 NYCRR 65-3.5; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 317).
Moreover, although the defendants contend that they submitted evidence showing that the plaintiff's assignor misrepresented his state of residence in connection with the issuance of the subject insurance policy, the defendants are precluded from asserting that defense, as a result of their untimely denial of the claim (see Fair Price Med. Supply Corp. v Travelers Indem. Co., 10 NY3d 556, 564; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d at 319; Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045, 1046-1047).
Although the defendants contend, on appeal, that North Carolina law should apply to this action, and that New York law does not preclude them from denying coverage, they did not raise that specific argument before the Supreme Court. Consequently, that contention is not properly before this Court (see Boudreau-Grillo v Ramirez, 74 AD3d 1265, 1268; Matter of Panetta v Carroll, 62 AD3d 1010).
Generally, motorcycle riders, whether operators or passengers, are not entitled to first-party no-fault insurance benefits from MVAIC (see Insurance Law § 5103[a], ; see also Quinones v Motor Veh. Acc. Indem. Corp., 6 Misc 3d 1007[A], 2004 NY Slip Op 51729[U]; 2-27 New Appleman New York Insurance Law § 27.04 [2d ed] ["Occupants of a motorcycle are excluded from coverage and are never entitled to no-fault benefits"]). A motorcycle is defined in the Insurance Law as "any motorcycle, as defined in [Vehicle and Traffic Law § 123], and which is required to carry financial security pursuant to article six, eight or forty-eight-A of the vehicle and traffic law" (Insurance Law § 5102[m] [emphasis added]). The Vehicle and Traffic Law defines a motorcycle as a "motor vehicle having a seat or saddle for the use of the rider and designed to travel on not more than three wheels in contact with the ground, but excluding a tractor" (Vehicle and Traffic Law § 123). Pursuant to the Vehicle and Traffic Law, class C motorcycles, which have a maximum speed of 20 miles per hour, are not required to carry insurance (see Vehicle and Traffic Law §§ 121-b, 2265). Construing these provisions together, the operator of or passenger on a class C motorcycle is entitled to no-fault benefits in the absence of any other statutory preclusion of benefits (see Tyler v Traveler's Ins. Co., 110 Misc 2d 471, 473 [operators of and passengers on "class C mopeds, minibikes and go-carts are entitled to first-party benefits under no-fault"]; 2-27 New Appleman New York Insurance Law § 27.04 ["Occupants of . . . limited-use class C motorcycles will not be excluded from coverage"]). Thus, not all motorcycles are required to carry insurance.
On its motion for summary judgment, MVAIC had the burden of establishing, by proof in admissible form, its prima facie entitlement to judgment as a matter of law (see CPLR 3212[b]; Zuckerman v City of New York, 49 NY2d 557, 561). To meet its burden, MVAIC was required to establish, prima facie, that Cruz was not a "qualified person" entitled to no-fault benefits either because she owned an uninsured vehicle despite being statutorily required to carry insurance, or because, at the time of the accident, she was operating a "motorcycle" within the meaning of Insurance Law § 5102(m). Here, MVAIC failed to meet its burden.
The only admissible evidence proffered by MVAIC as to the type of vehicle that Cruz was operating when the accident occurred was a form completed on her behalf, setting forth her notice of an intention to make a claim for no-fault benefits (hereinafter the claim form). The claim form was signed by Priscilla Garcia—Cruz's mother and guardian—and indicated that Cruz was the owner and operator of a vehicle designated as vehicle #1, which was described as a "2004 Mini-Bike" for which no insurance existed. Critically, the make and model of the vehicle designated as vehicle #2 is listed as "unknown." Clearly, the term "Mini-Bike" refers to some type of [*4]motorized, two or three-wheeled vehicle (see Oxford English Dictionary Online, http://www.oed.com [accessed July 27, 2010] [defining "minibike" as "(a) small motorcycle with a low-power engine, designed for off-road use and sometimes having three wheels]; Merriam-Webster Online Dictionary,http://www.Merriam-Webster.com [accessed July 27, 2010] [defining "minibike" as "a small one-passenger motorcycle with a low frame and raised handlebars"]). Nevertheless, the use of the word "Mini-Bike" in the claim form, standing alone, is insufficient to establish whether Cruz's vehicle was or was not a class C motorcycle with a maximum speed of 20 miles per hour, because the critical factor in determining a motorcycle's class is its maximum speed (see Vehicle and Traffic Law § 121-b). Thus, MVAIC failed to establish that the vehicle that Cruz was operating was either an uninsured motor vehicle for which she was required to carry insurance, or a motorcycle of a class which required her to carry insurance.
Since MVAIC failed to meet its prima facie burden on its motion for summary judgment, the burden never shifted to Englington to submit, in proper admissible form, evidence sufficient to raise a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324), despite MVAIC's contention that Englington had the burden of proving that Cruz's vehicle was not required to carry insurance, and failed to meet that alleged burden. In its brief, MVAIC asserts that "[i]t is well settled in this Department that the party seeking benefits from MVAIC bears the burden of establishing that the injured party is a qualified person' who complied with all applicable requirements of Article 52." However, in light of the procedural posture of this case, MVAIC misconstrues the burden applicable to the parties, which is a fundamental aspect of a motion for summary judgment. As the movant, MVAIC must first come forward with admissible evidence demonstrating, prima facie, the absence of material issues of fact and that, on those facts, it is or would be entitled to judgment as a matter of law. MVAIC's burden on a motion for summary judgment cannot be satisfied merely by pointing out gaps in the plaintiff's case (see e.g. Shafi v Motta, 73 AD3d 729, 730; Gamer v Ross, 49 AD3d 598, 600; Totten v Cumberland Farms, Inc., 57 AD3d 653, 664; DeFalco v BJ's Wholesale Club, Inc., 38 AD3d 824, 825).
From time to time I'm going to post no-fault cases. Not because anyone cares, but so that I will have a place to find them. Nothing to see here.
It should be noted that the surgery section of the Fee Schedule denotes different percentages of payment based on whether a participating surgeon is acting as a "Surgical Assistant" or a "Co-Surgeon". A Surgical Assistant bills at 16%, while Co-Surgeons are directed to apportion billing in relation to the responsibility and work done. (See New York Workers' Compensation Fee Schedule, Surgery, page 4). Defendant's witness did not offer testimony regarding whether Plaintiff should have billed as a Surgical Assistant or a Co-Surgeon. Plaintiff's rebuttal witness, Dr. Giugliano , testified that the classifications are interchangeable and he was entitled to bill as a co-surgeon. Absent proof to the contrary, the Court finds that Plaintiff was entitled to bill as a Co-Surgeon under the Fee Schedule.
With respect to Plaintiff utilizing the surgery CPT codes, the Court finds that Plaintiff successfully rebutted Defendant's testimony and Plaintiff was entitled to use these CPT codes as the procedures were not listed under the chiropractic fee schedule. When a charge for a reimbursable service has not been scheduled by the superintendent, then the provider shall establish a fee consistent with other fees for comparable procedures shown in such schedule subject to review by the insurer. Id; See also Studin v. Allstate Ins. Co., 152 Misc 2d 221 (NY Dist. Ct. 1991). Therefore, the Court finds that Plaintiff established that the procedures were properly billed pursuant to the Fee Schedule and Plaintiff is entitled to be reimbursed for the services performed.
As MVAIC has submitted an affidavit swearing that plaintiff's assignor did not file a notice of intention to make a claim, police report or household affidavit, defendant's moving papers make a prima facie showing that plaintiff's assignor is not a "qualified person" (Insurance Law § 5202[b]) and, thus, that he is not a "covered person" (Insurance Law § 5221[b]).[FN1] Plaintiff's first argument in opposition is that defendant may not raise this "issue" to "obviate the 30-day requirement which would frustrate the purpose and objective of the No-Fault Law" (aff. in opp., para. 4).Plaintiff is incorrect.
In Hospital for Joint Diseases v Travelers Property Cas. Ins. Co., 9 NY3d 312, 849 NYS2d 473 (2007), the Court of Appeals recognized "a narrow exception to this preclusion remedy for situations where an insurance company raises a defense of lack of coverage (citation omitted). In such cases, an insurer who fails to issue a timely disclaimer is not prohibited from later raising the defense because the insurance policy does not contemplate coverage in the first instance, and requiring payment of a claim upon failure to timely disclaim would create coverage where it never existed' (citation omitted)".The Appellate Division, First Department recently held that, like insurers raising lack of coverage, MVAIC may raise the issue of lack of qualification at any time, and this issue is not subject to the thirty-day preclusion rule. MVAIC v Interboro Medical Care & Diagnostic PC, 73 AD23d 667, 902 NYS2d 45 (1st Dept 2010). [*3]Plaintiff's second argument in opposition is that defendant improperly sent verification requests to plaintiff and its attorneys, rather than to plaintiff's assignor Mr. Shalina. This argument ignores the documents submitted on the motion. Plaintiff's NF-3 lists only "N/A, N/A, NY 11235" as Mr. Shalina's address. As defendant claims there was no record of Mr. Shalina in its files, it would have been impossible for defendant to send anything to Mr. Shalina without having been given his address by plaintiff.
In this case, plaintiff apparently rendered services to "Mr. Shalina" (assuming that was his real name) on five separate occasions without ever obtaining any identification or proof of address. Perhaps because plaintiff had no other place to send the bill, it sent the bill to MVAIC. Because plaintiff's assignor, Mr. Shalina, never qualified for benefits from MVAIC, his assignee, plaintiff, who stands in his shoes, is not entitled to benefits from defendant either.
The bold is mine. Nevermind, no bold.
One more thing. Roy Mura posted about a new circular letter re: cancellation for lack of payment.

References: § 5103
 § 27
 § 123
 § 5102
 § 123
 § 27
 § 5102
 § 121
 v. 
 § 5202
 § 5221