Lenox Hill Radiology & MIA, P.C. v Global Liberty Ins. Co. of N.Y., 2018 NY Slip Op 51810(U)(App. Term 2d Dept. 2018)
The relevance here is that my friend Rookie took the District Court published cased and convinced some Civil Court judges that we could not prove mailing. It made me feel like the partner who could not prove the no show. Anyway, that case was reversed and so Rookie will take the case out of his Room 809 oral argument tool bag I am assuming.
“Contrary to the determination of the District Court, defendant established the timely mailing of the initial and follow-up verification requests (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 ). As defendant also sufficiently established that it had not received the requested verification, and plaintiff did not show that the verification had been provided to defendant prior to the commencement of the action, the 30-day period within which defendant was required to pay or deny the claims did not begin to run”
Solution Bridge, Inc. v State Farm Mut. Auto. Ins. Co., 2018 NY Slip Op 51648(U)(App. Term 2d Dept. 2018)
“Contrary to plaintiff’s contentions, defendant’s proof was sufficient to demonstrate prima facie that it had timely mailed initial and follow-up verification requests (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 ); that it had not received the requested verification; and that it had timely denied the claim on that ground. However, as plaintiff further argues, the affidavit submitted by plaintiff in opposition to defendant’s motion was sufficient to give rise to a presumption that the requested verification had been mailed to, and received by, defendant (see id.). In light of the foregoing, there is a triable issue of fact as to whether plaintiff provided the requested verification.”
Has anyone sought to ask the Second Department to review these cases? i am hard-pressed to imagine that an affidavit without documentary support is sufficient to raise an issue of fact. Or, are we all sheep?
Matter of Progressive Cas. Ins. Co. (Elite Med. Supply of N.Y., LLC), 2018 NY Slip Op 04122 (4th Dept. 2018)
“In his awards, the master arbitrator found that the arbitrator had misapplied the 120-day rule, reasoning that, pursuant to that rule, a claimant who responds within the requisite 120-day period with a “reasonable justification” is permitted to have that objection decided by the arbitrator and, if overruled by the arbitrator, is to be afforded the opportunity to produce the requested information and allow the insurer to base its decision on such information (11 NYCRR 65-3.8 [b] ). Contrary to petitioners’ contention, the master arbitrator did not impermissibly perform a de novo review of the evidence. Rather, the master arbitrator vacated the arbitrator’s awards based on “an alleged error of a rule of substantive law” (Matter of Acuhealth Acupuncture, P.C. v Country-Wide Ins. Co., 149 AD3d 828, 829 [2d Dept 2017] [internal quotation marks omitted]). Thus, we conclude that the court’s decision to uphold the master arbitrator’s awards in this case was rational (cf. id.).”
This case highlights how important it is to respond and object to verification demands. The worst thing that can happen, should an objection be lodged, is that the denial of the claim is without prejudice. I would sense in certain circumstances an objection to an attendance at an EUO landing in a denial could also be a dismissal without prejudice. The 120-day rule has been neutered and it may have ramifications far beyond 65-3.5 and 65-3.6.
Acupuncture Healthcare Plaza I, P.C. v Allstate Ins. Co., 2017 NY Slip Op 50939(U)(App. Term 2d Dept. 2018)
I think I failed to specifically comment on this case. In light of Atlantic Radiology, we now have a difference of opinion between the courts.
Recover Med. Servs., P.C. v Ameriprise Ins. Co., 2017 NY Slip Op 51892(U)(App. Term 2d Dept. 2017)
Upon review of my blog, I failed to note this case.
Atlantic Radiology Imaging, P.C. v Travelers Prop. Cas. Co. of Am., 2018 NY Slip Op 50053(U)(App. Term 1st Dept. 2018)
“It being undisputed on this record that plaintiff failed to fully respond to the defendant-insurer’s verification requests, defendant established its prima facie entitlement to summary judgment dismissing the underlying first-party no-fault claims as premature (see St. Vincent Med. Care, P.C. v. Country Wide Ins. Co., 80 AD3d 599, 600 ). Even accepting plaintiff’s speculative assertion that defendant’s followup verification request was issued two days beyond the 10-day period prescribed by the regulation (see 11 NYCRR 65-3.6), this does not, under the circumstances here presented, deprive defendant of the benefit of the tolling of the 30-day period during which an insurer must pay or deny the claim (see Infinity Health Prods., Ltd. v Eveready Ins. Co., 67 AD3d 862 ; Triangle R Inc. v Praetorian Ins. Co., 30 Misc 3d 129[A], 2010 NY Slip Op 52294[U] [App Term, 1st Dept 2010]).”
Two points to be fleshed out here. First, all verification was not received. Problem. Second, the follow-up can be late without consequence. I sense divergence from the Second Department (AT).
Initially, a late follow-up according to the AT second department eliminated the toll. The AT First says otherwise.
Second, how do you harmonize the line of AT 2nd cases saying that the affidavit of compliance with verification is sufficient whereas this case which seems to look for record support regarding received verification?
Doctor Goldshteyn Chiropractic, P.C. v Travelers Indem. Co., 2017 NY Slip Op 51816(U)(App. Term 2d Dept. 2017)
“In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint.
Contrary to plaintiff’s contention, the record demonstrates that defendant did not receive requested verification and, thus, that the action is premature (see Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 ). Indeed, on appeal, plaintiff notes that it had partially responded to defendant’s verification request”
Again, the “partial response paradigm” appears to be fatal to the medical provider. I suppose the correct record has to be established to see if an objection to verification will destroy an insurance carrier’s summary judgment motion?
City Care Acupuncture, P.C. v Allstate Prop. & Cas. Ins. Co., 2017 NY Slip Op 51839(U)(App. Term 2d Dept. 2017)
“In support of plaintiffs’ motion for summary judgment and in opposition to defendant’s cross motion, plaintiffs submitted affirmations from plaintiffs’ counsel and annexed purported verification responses which expressly stated that plaintiffs were not providing responses to some of defendant’s verification requests. As a result, contrary to plaintiffs’ contention, the record demonstrates that defendant had not received all of the requested verification and, thus, that the action is premature”
This is interesting because we are left to reason that certain verification was objected to and certain verification was provided. The Court held that the failure to provide the requested verification (or to indicate where the verification could be obtained) renders the action premature. This Court has often stated that the failure to fully comply with verification renders the matter premature.
TAM Med. Supply Corp. v Tri State Consumers Ins. Co., 2017 NY Slip Op 51247(U)(App. Term 2d Dept. 2017)
“In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint on the ground that defendant had timely and properly denied the claim at issue based upon plaintiff’s failure to provide requested verification within 120 days of the initial verification request (see 11 NYCRR 65-3.5 [o]). ”
The case was followed the usual rubric where the Court found a non-specific affidavit sufficient to raise an issue of fact. What is more interesting, however, is the Court held that the a 120-day denial had to be timely issued. This begs the question: When is a 120-day denial “timely” denied? Good question.
Daily Med. Equip. Distrib. Ctr., Inc. v Interboro Ins. Co., 2017 NY Slip Op 50958(U)(App. Term 2d Dept. 2017)
“In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment, and defendant cross-moved for summary judgment dismissing the complaint on the ground that the action was premature because defendant had timely and properly requested verification and the verification had not been provided to defendant. Insofar as is relevant to this appeal, the Civil Court denied defendant’s cross motion and found that the only remaining issue for trial was whether defendant had received the verification it had requested.
As defendant demonstrated that it had not received the requested verification, and plaintiff did not show that the verification had been provided to defendant prior to the commencement of the action, the 30-day period within which defendant was required to pay or deny the claims did not begin to run (see 11 NYCRR 65-3.5 [c]; 65-3.8 [a])”
The verification to be received was an affidavit of receipt of supplies from the EIP. I am curious if the outcome would have changed had a delivery receipt -should it have existed – was annexed to the answering papers,