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This article is part of our ongoing no-fault coverage, with 271 published articles analyzing no-fault 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.
Policy Exhaustion Defense Falls Short on Evidentiary Foundation
Insurance companies frequently assert policy exhaustion as a defense in New York no-fault insurance cases, claiming they’ve already paid out the maximum benefits available under a policy. However, simply claiming exhaustion isn’t enough – insurers must provide proper legal foundation for their payment records. If you’re dealing with a no-fault insurance defense matter, an experienced attorney can help protect your rights.
A recent Appellate Term decision demonstrates how technical evidentiary requirements can derail what might seem like a straightforward defense. The case highlights the ongoing challenges insurance companies face when trying to establish their payment histories in court, particularly regarding the foundational requirements under CPLR 4518(a).
This ruling serves as a reminder that even routine insurance defense strategies require careful attention to procedural requirements. Claims representatives’ affidavits must meet specific legal standards to be admissible as evidence of payments made.
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JPC Med., P.C. v State Farm Mut. Auto. Ins. Co., 2022 NY Slip Op 50562(U)(App. Term 2d Dept. 2022)
“To obtain summary judgment on its asserted defense of policy exhaustion, defendant had to prove that it had paid the limits of the policy in accordance with 11 NYCRR 65-3.15 (see Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294 ; Alleviation Med. Servs., P.C. v Allstate Ins. Co., 55 Misc 3d 44 , affd 191 AD3d 934 ). Here, defendant failed to demonstrate, as a matter of law, that it had made any payments under the policy because, as plaintiff argues, defendant’s claim specialist did not lay a sufficient foundation for the payment log, upon which defendant relied, to be accepted as proof that the payments listed therein had been made (see CPLR 4518 ; People v Kennedy, 68 NY2d 569 ; Charles Deng Acupuncture, P.C. v 21st Century Ins. Co., 61 Misc 3d 154, 2018 NY Slip Op 51815 )”
The 3.15 argument is what it is. But the failure to satisfy 4518(a)? Those are five lines in the a claims rep affidavit.
Key Takeaway
This decision underscores that insurance companies cannot simply submit payment logs without proper foundational testimony. Even seemingly minor deficiencies in a claims representative’s affidavit can defeat a policy exhaustion defense, emphasizing the importance of meticulous documentation in no-fault insurance litigation.
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Legal Context
Why This Matters for Your Case
New York's no-fault insurance system, established under Insurance Law Article 51, is one of the most complex insurance frameworks in the country. Every motorist must carry Personal Injury Protection coverage that pays medical expenses and lost wages regardless of fault, up to $50,000 per person.
But insurers routinely deny valid claims using peer reviews, EUO scheduling tactics, fee schedule reductions, and coverage defenses. The Law Office of Jason Tenenbaum has handled over 100,000 no-fault cases since 2002 — from initial claim submissions through arbitration before the American Arbitration Association, trials in Civil Court and Supreme Court, and appeals to the Appellate Term and Appellate Division. Jason Tenenbaum is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
His 2,353+ published legal articles on no-fault practice are cited by attorneys throughout New York. Whether you are dealing with a medical necessity denial, an EUO no-show defense, a fee schedule dispute, or a coverage question, this article provides the kind of detailed case-law analysis that helps practitioners and claimants understand exactly where the law stands.
About This Topic
New York No-Fault Insurance Law
New York's no-fault insurance system requires every driver to carry Personal Injury Protection (PIP) coverage that pays medical expenses and lost wages regardless of who caused the accident. But insurers routinely deny, delay, and underpay valid claims — using peer reviews, IME no-shows, and fee schedule defenses to avoid paying providers and injured claimants. Attorney Jason Tenenbaum has litigated thousands of no-fault arbitrations and court cases since 2002.
271 published articles in No-Fault
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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.
If you need legal help with a no-fault matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
