More on defective denialsMarch 12, 2011

St. Vincent’s Hosp. & Med. Ctr. v New Jersey Mfrs. Ins. Co., 2011 NY Slip Op 01828 (2d Dept. 2011)

“The plaintiff, St. Vincent’s Hospital & Medical Center, as assignee of Tula Huillca, demonstrated its prima facie entitlement to judgment as a matter of law. While the defendant insurer timely issued two denials of claim within 30 days of its receipt of the completed hospital facility forms (NYS Form N-F 5), those denials of claim, which incorrectly stated the amount of the bill and the amount in dispute, and incorrectly listed Tula Huillca as the applicant for benefits instead of the plaintiff, were fatally defective

So the insurer gets punished because it put the UB-92 value on the NF-10 instead of the DRG value, and listed the assignee as the applicant.  Is this really fair?  Seriously?  They need to wake up (a bit) on Monroe Place.

14 Responses

  1. Larry Rogak says:

    The triumph of form over substance. The “i-dotters” and “t-crossers” have seized power.

  2. SunTzu says:

    I think another way to look at this case is that the carrier attempted to pass off a denial regarding a different applicant and claim as a denial for the subject claim.

    • JT says:


      My suspicion is that the carrier put the UB-92 instead of the DRG value in the amount of bill box on the Form, NF-10. This happens frequently with many fee schedule vendors who adjust hospital bills. The “applicant” deficiency is just plain ridiculous, and the Appellate Division should be ashamed of themselves. Are these the deficiencies what the Court of Appeals had in mind when they introduced the Cirucci Ins Law 3420 preclusion remedy to no-fault? I have to doubt that.

      Perhaps, the carriers need to start changing the venue on these Henig hospital cases out of Nassau to either the First or Third Department. I think the First Department (Appellate Division) would have probably ruled differently. In my mind, enough is enough already.

      Having no-fault guided by Appellate Division, Second Department precedent has not exactly been too kind to the carriers.

  3. slick says:

    The denial is important. It’s intended to apprise the claimant of the issues at stake so that they can make an informed decision as to their course of action. If the denial has the wrong patient name and wrong amount, how can the provider know that it relates to the claim at issue? It makes me think of the likelihood of confusion standard from trademark law.

  4. Raymond J. Zuppa says:

    Deficiencies? Is that the standard. I thought the denial was supposed to clearly notify the layperson claimant — not an attorney — of why a claim is being denied. When the insurer gets the claimant wrong it is hard to notify the claimant why the claim was denied. Isn’t it all about the amount of the bill and the amount in dispute. I thought that was a big part of the no fault law. I don’t do much no fault but I thought the edict was “prompt payment.” Its about the Benjamins J.T. We all have families. We all need to eat. Even doctors.

    Seems like the Appellate Division 2nd Dep’t. is wide awake with Justices that refuse to be swayed by politics. The way appointed Judges are supposed to act — use a little bit of that above the political fray logic and look to the evil a statute was intended to remedy and what a statute was intended to do.

    Look at the great Justice Stevens of the U.S. Supreme Court. Nominated by Ford — a conservative; called a Liberal and wrote the dissent in the case that said you could burn the flag. He had that “you can’t touch me now” way of rolling. He called them as he saw them.

    Maybe insurance companies should stop ripping off hospitals for goodness sake. These aren’t mills.

    Maybe everyone else besides the Second Department is on heavy amounts of Ambien CR mixed in with some Valium.

    I’m wide awake. So is the Appellate Division Second Department.

  5. Raymond J. Zuppa says:

    Additionally J.T. your legal analysis of the case was about at the same level as Rogak’s. Sorry … I mean sorry to Larry.

  6. SunTzu says:

    “The “applicant” deficiency is just plain ridiculous, and the Appellate Division should be ashamed of themselves. Are these the deficiencies what the Court of Appeals had in mind when they introduced the Cirucci Ins Law 3420 preclusion remedy to no-fault? I have to doubt that.”

    The entire appellate division law regarding the invalidity of blanket forms would be rendered meaningless assuming the carrier could just fill in inaccurate information.

    Further, if the denial misidentifies the applicant and bill amount, the denial does not pertain to the subject claim, and you have only the insurer’s subjective complaints that it does.

    Your position presumes that the insurer should be entited to set forth wrong information in the fields as to require the provider to conduct an investigation to determine which claim the form applies to.

    Moreover, assuming the carrier can “game” the fields by the inclusion of inaccurate information, it can seek to gloss over any admission of wrongdoing that would be ordinarily attendant to the properly completion of forms. There is a reason why the Ins. Dept. requires the use of prescribed forms, see 11 NYCRR 65, Appendix 13.

    • JT says:

      But Sun,

      It is the UB-92 amount which by regulation is submitted with the NF-5 or NF-4 and constitutes the hospital’s prima facie case. There is very logical basis for this incorrect data; it is not as if some number is being picked out of a hat and placed in the amount of bill box. If you look at the record in these Henig cases, you will see the UB-92 with the NF-5. For a medical provider to claim “prejudice” or to assert that this is a “fatal defect” is incredulous.

      My analysis is rock solid, which is more than can be said for the analysis that offered by the founder and sole contributor to what was the Pit.

  7. Raymond J. Zuppa says:

    I resemble that remark … All I do is offer logic not unsupported allegations.

  8. Raymond J. Zuppa says:

    And I still maintain J.T. that your analysis had a certain Rogakian quality to it.

    • JT says:

      It is an issue that i think the courts have gone overboard with. It carries the same logic as what happened to Eva on her appeal.

  9. Raymond J. Zuppa says:

    Everything must be viewed through the prism of what was given up to have this alleged “no fault” system of alleged “prompt payment.”

    I used to think that people who sued for car accidents were wimps. But let me tell you I have revisted that view point. A good high speed rear ending that caused the offending idiot’s car to burn to a literal crisp is a case in point. The guy’s out cold on his steering wheel airbag. I pull him out and carry him down the Northern Parkway. He comes to. He’s still clutching his keys. He runs back to his burning car — opens the trunk and retrieves his golf clubs. Then he proceeds to run down the Northern Parkway where the “Church Bus” picks him up.

    My neck hurt pretty bad for six months. Messed up my workouts. I didn’t sue but you know the guy was an idiot.

    Today in downtown Brookly I am stopped at the cross walk waiting to make a left turn. There are people in the cross walk. This big SUV pulls up behind me right up you know where and starts beeping the horn. Am I supposed to run these people over. So I popped out of the car and told him to shut up or I was going to beat him to death. He complied because that’s the way I roll.

    My point is that we — the citizens — gave up a right. The commonlaw right to sue. Now the Court of Appeals said: “Hey the government legislates away people’s rights all the time.” Yes you do Court of Appeals. That’s always been my exact point.

    But anyway if you take away the right (RIGHT) to sue for pain and for medical bills and lost wages — if you take that away — you better follow the rules to Rogak’s “T” and “i.”

    Barshay is fond of letting us know how much profits the No Fault insurers are making. I maintain it is stolen profits. The government is a co-conspirator.

    The Appellate Division knows why we have No Fault. The trade off. As should every court.

  10. Larry Rogak says:

    This is like when an umpire makes a really bad call at a baseball game. If the bad call favors your team, the ump is a genius. If it hurts your team, he’s a blind, crippled, corrupt retard whose mother made a living entertaining strangers.

  11. Raymond J. Zuppa says:

    You remember those days Larry when the Courts acted like umpires. Calling balls and strikes. Sustain or over rule. Hearsay or exception.

    Now it seems like the Court sometimes takes the bat and whacks one out of the park for one of the teams playing.

    Or throws the key block that springs the running back.

    A good court is a good referee. Nothing more and nothing less.

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