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Additional VerificationOctober 26, 2019

New Horizon Surgical Ctr., LLC v Travelers Ins. Co., 2019 NY Slip Op 51690(U)(App. Term 2d Dept. 2019)

“Contrary to plaintiff’s contention, defendant was not required to pay or deny plaintiff’s claims upon receipt of a “partial response” to defendant’s verification requests (see 11 NYCRR [*2]65-3.8 [a] [1]; [b] [3]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2004] [“A claim need not be paid or denied until all demanded verification is provided”]).”

Two thoughts here. First, how do we justify the Rybak general compliance affidavit? Second, how do arbitrators still hold in the general sense that an objection letter or “communication” must be responded in order to continue the toll. The Court is clear – provide it or lose.

I can see two exceptions to the second point. First, a response that says we do not have it is a complete response. Second, a response that objects because the sought after verification is palpable improper. I must assume this case fits under exception two. Maybe the Court found the demand reasonable? The problem is like the definition of medical necessity, the appeals courts have not given us guidance of where the reasonableness line (if it even exists) is drawn.

One Response

  1. Rookie says:

    This Decision Like EVERYTHING Lately Coming from the Term, is WRONG:

    See DFS Opinion Letter

    https://www.dfs.ny.gov/insurance/ogco2006/rg060814.htm (Pursuant to N.Y. Ins. Law § 5106(a) (McKinney 2000), (“If proof is not supplied as to the entire claim, the amount which is supported by proof is overdue if not paid within thirty days after such proof is supplied.”)(” it should be noted that where a claimant supplies at least a part of the information requested and the insurer is able to make a determination as to the sufficiency of proof as to part of the claim, Section 5106(a), as referenced above, requires the insurer to make a determination to pay or deny the part of the claim within 30 days after receipt of the requested verification”)

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