NO-FAULT – VERIFICATION – INSURANCE LAW § 5106(A) – UNTIMELY DENIAL – MEDICAL NECESSITY DEFENSE
North N.Y. Med. Care, P.C. a/a/o Miledy Corniel v. New York Cent. Mut. Fire Ins. Co.
(App. Term, 2nd Dept., decided 7/10/2008)
This decision reminds no-fault insurers that the 30-day pay or deny period of Insurance Law § 5106(a) and Regulation 68 (11 NYCRR § 65-3.8) is reduced by the number of days a request for additional verification is sent after 10 business days from receipt of a prescribed claim form.
According to the decision, New York Central requested additional verification from plaintiff medical provider 12 days after receiving its NF-3 verification of treatment form. Section 65.15(d)(2) provides that additional verification required by an insurer is to be requested within 10 business days of receipt of a prescribed claim form. Pursuant to § 65-3.8(j), therefore, the 30-day period within which New York Central was required to pay or deny plaintiff's claim was reduced to 28 days.
The decision indicates that New York Central received the requested additional verification on May 16, 2001. Adding 28 and subtracting 31 made June 13, 2001 the 30-day deadline to pay or deny the plaintiff's bill. New York Central denied plaintiff's bill (or it appears a portion of it) on June 14, 2001.
In REVERSING Nassau District Court's order denying summary judgment to plaintiff, the Appellate Term held that "[a]s defendant did not deny plaintiff's claim until June 14, 2001, defendant's denial of plaintiff's claim was untimely and defendant is precluded from raising its proffered defense of lack of medical necessity[.]"