Key Takeaway
Court distinguishes between Mallela defense and over-billing claims in no-fault insurance case, ruling that billing fraud doesn't qualify for extended defense timeline.
This article is part of our ongoing attorney fee coverage, with 164 published articles analyzing attorney fee issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
In New York no-fault insurance law, timing is everything when it comes to raising defenses against medical provider claims. Insurance companies typically have just 30 days to deny claims, but there’s a narrow exception known as the “Mallela defense” that allows extended time limits for certain coverage-related challenges. Understanding the distinction between this specialized defense and standard over-billing claims can mean the difference between a successful challenge and paying attorney fees.
The recent Court-Wide Insurance case highlights a crucial distinction that practitioners in New York no-fault insurance law must understand. When an insurance company attempts to raise defenses outside the standard 30-day window, courts scrutinize whether the challenge truly qualifies for the Mallela exception or falls into ordinary coverage disputes.
Jason Tenenbaum’s Analysis:
Matter of Country-Wide Ins. Co. v Bay Needle Acupuncture, P.C.2018 NY Slip Op 08238 (1st Dept. 2018)
This was an interesting case that discusses the distinction between the defenses of “Mallela” and “over-billing”.
“We find that petitioner’s defense is not a Mallela defense. It is based on the guilty plea of Andrey Anikeyev, who, according to petitioner, is respondent’s “de facto owner,” to conspiracy to commit health care fraud and mail fraud. Anikeyev pleaded guilty to billing insurance companies “for health care services for time periods in excess of the actual time period the patient spent with acupuncturist.” This plea supports nothing more than “a defense that the billed-for services were never rendered,” which is “more like a normal’ exception from coverage (e.g., a policy exclusion) a lack of coverage in the first instance” (Fair Price Med. Supply Corp. v Travelers Indem. Co., 10 NY3d 556, 565 ), and therefore does not fall into the “settled law recognizing a narrow exception to the 30-day deadline for defenses based on lack of coverage”
And then comes the real nail in the coffin: “Respondent is entitled to reasonable attorneys’ fees for this appeal, to be determined by Supreme Court”
Key Takeaway
Courts carefully distinguish between true Mallela defenses (which challenge fundamental coverage issues) and standard over-billing claims. When insurance companies mischaracterize billing fraud as a Mallela defense to avoid the 30-day deadline, they risk not only losing the case but also paying the medical provider’s attorney fees—a costly consequence that underscores the importance of properly categorizing coverage defenses.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
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Frequently Asked Questions
How are attorney fees awarded in no-fault cases?
Under 11 NYCRR §65-4.6, if a no-fault claimant prevails at arbitration or in court, the insurer may be required to pay attorney fees. The fee schedule is set by regulation — typically 20% of the first $2,000 recovered and 10% of amounts above that, with a minimum fee. These fees are separate from and in addition to the benefits recovered.
Can I recover attorney fees in a personal injury lawsuit?
In New York, each party typically pays their own attorney fees (the "American Rule"). Exceptions exist in certain statutory claims — for example, employment discrimination cases under federal or state law may include fee-shifting provisions. In personal injury cases, the attorney fee is usually a contingency percentage agreed upon with the client.
What is the fee schedule for no-fault arbitration?
The fee schedule under Regulation 68 (11 NYCRR §65-4.6) provides for a reasonable attorney fee based on the amount recovered. The schedule is designed to ensure claimants have access to legal representation while keeping fees proportional to the recovery. Disputes over the amount of attorney fees can be resolved by the arbitrator or court.
What are common coverage defenses in no-fault insurance?
Common coverage defenses include policy voidance due to material misrepresentation on the insurance application, lapse in coverage, the vehicle not being covered under the policy, staged accident allegations, and the applicability of policy exclusions. Coverage issues are often treated as conditions precedent, meaning the insurer bears the burden of proving the defense. Unlike medical necessity denials, coverage defenses go to whether any benefits are owed at all.
What happens if there's no valid insurance policy at the time of the accident?
If there is no valid no-fault policy covering the vehicle, the injured person can file a claim with MVAIC (Motor Vehicle Accident Indemnification Corporation), which serves as a safety net for people injured in accidents involving uninsured vehicles. MVAIC provides the same basic economic loss benefits as a standard no-fault policy, but the application process has strict requirements and deadlines.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
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