Key Takeaway
Court ruling on cessation of no-fault treatment - when plaintiffs must prove benefit termination and reasonable explanation for stopping therapy in 5102(d) cases.
Ramkumar v Grand Style Transp. Enters. Inc., 2013 NY Slip Op 06638 (2013)
“The Appellate Division’s requirement that plaintiff either offer documentary evidence to support his sworn statement that his no-fault benefits were cut off, or indicate that he could not afford to pay for his own treatment, is an unwarranted expansion of Pommells. Plaintiff testified at his deposition that “they” (which a reasonable juror could take to mean his no-fault insurer) cut him off, and that he did not have medical insurance at the time of the accident. While it would have been preferable for plaintiff to submit an affidavit in opposition to summary judgment explaining why the no-fault insurer terminated his benefits and that he did not have medical insurance to pay for further treatment, plaintiff has come forward with the bare minimum required to raise an issue regarding “some reasonable explanation” for the cessation of physical therapy.”
This is interesting because the Appellate Division in the 5102(d) context held that the failure to present an NF-10 stating that benefits were cut off or to affirmatively state that Claimant did not have insurance other that no-fault would non-suit the plaintiff on a threshold motion.
The Court I think is now holding that an insurance carrier has to affirmatively state as part of its motion for summary judgment that the Claimant had medical insurance other that no-fault in order to defeat this contention.. Alternatively, and this is interesting, the issue of reasonableness of cessation of treatment now goes to the jury. This is a radical change because cessation of treatment has never been an issue for a jury and, in fact, there is no PJI for this issue.
As to the pure first-party no fault issue, the dissent says it all:
“he legislative intent underlying the No-Fault Law was to weed out frivolous claims and limit recovery to significant injuries” (Dufel v Green, 84 NY2d 795, 798 ). Since the statute was enacted, false claims of “serious injury” have done much to undermine the legislative goal. A number of courts, including ours, have pointed out that the no-fault system is riddled with abuse (see Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 861 [*3] [“Between 1992 and 2001, reports of suspected automobile insurance fraud increased by 275%, the bulk of the increase occurring in no-fault insurance fraud”]; Pommells v Perez, 4 NY3d 566, 571 [“Abuse … abounds”]; Perl v Meher, 18 NY3d 208, 214 [“No-fault abuse still abounds today”]; Fair Price Med. Supply Corp. v Travelers Indem. Co., 9 Misc 3d 76, 78 [“the steep increase in fraudulent no-fault benefits claims”], aff’d 42 AD3d 277 , aff’d 10 NY3d 556 ; id., 9 Misc 3d at 83 [“fraudulent claims are an ever increasing issue”]; Metroscan Imaging P.C. v GEICO Ins. Co., 8 Misc 3d 829, 831-832 [“unfortunately well documented … deluge of fraudulent claims”]).”
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Legal Update (February 2026): The standards for establishing cessation of treatment under Insurance Law §5102(d) discussed in this 2013 analysis may have evolved through subsequent appellate decisions and regulatory amendments. Practitioners should verify current case law requirements for documentary evidence of benefit termination and the burden of proof regarding alternative insurance coverage, as courts have continued to refine these evidentiary standards in threshold motions.
