The feigned verification response does not slice it – a break from the law as certain arbitrators construe itMarch 13, 2017
St. Barnabas Hosp. v Government Employees Ins. Co., 2017 NY Slip Op 27056 (2d Dept. 2017)
(1) “The Plaintiff’s position that the verification request was improper because it is not required under the insurance regulations or no fault law is without merit. The Defendant, GEICO, referenced Circular Letter No. 4 dated January 12, 2011, issued by the State of New York Insurance Department, in its original request for additional verification. The purpose of the Circular Letter is to advise no-fault insurers and health insurers of the amendment of Insurance Law §5103(b)(2) and to interpret the regulations related thereto.”
(2) “The Court also disagrees with the Plaintiff’s contention that it fully responded to the Defendant’s verification requests by merely stating, “[t]he patient received ‘Necessary Emergency Health Services’ during his admission at the hospital.” The Plaintiff’s response is vague in that it fails to delineate whether some, most or all of the services were in fact “necessary emergency health services”.
(3) Thus, as the Defendant correctly maintains, the Plaintiff’s initial claim for payment was premature and was not complete until the Defendant received additional verification of the claim as requested (See 11 NYCRR 65-3.8(a)(1), (b)(3); Nyack Hosp. v. State Farm Mut. Auto. Ins. Co., 19 AD3d 569 [2d Dept. 2005]).
(4) Where, as here, the insurer presents sufficient evidence that it timely requested additional verification and the hospital fails to provide the information requested, the complaint must be dismissed as premature (St. Vincent’s Hosp. of Richmond v. American Transit Ins. Co.. 299 AD2d 338 [2d Dept. 2002]).
The context of the within matter involves the when the insurance carrier is liable to a hospital for no-fault coverage following a patient’s “stabilization”. What is noteworthy here is that in response to verifications, the hospital objected and GEICO failed to communicate with the hospital. Most arbitrator’s apply a 13 year old Civil Court case, stating that an insurance carrier must respond to an objection at its own peril. All Health Med. Care, P.C. v. Gov’t Employees Ins. Co., 2 Misc. 3d 907, 911, (Civ. Ct. Queens Co. 2004). This case is contra. And, it makes sense. If the provider sends documentation that is unresponsive to the verification, then why does the insurance carrier have to play “ping pong”. Upon objecting to a verification or providing unresponsive information. the claim is ripe for arbitration or litigation.
In this case, the Court held that objection lacked merit, did not require the insurance carrier to do anything further, and dismissed the claim. In my mind, that is the right call.