Upon a medical provider’s or Claimant’s violation of the 30-day rule or 45-day rule, and an insurance carrier’s timely denial thereto, what happens if a Plaintiff/Claimant subsequent to this denial proffers a reasonable justification for the late submission?
It would appear that the Carrier would have a real problem, since its only defense to payment of the otherwise valid claim would not be sustainable.
Such appears to be the case in the recent Appellate Term matter of:
Bronx Expert Radiology v Clarendon Natl. Ins. Co.
2009 NY Slip Op 50747(U)(App. Term 1st Dept. 2009)
In Bronx Expert, a triable issue of fact was set forth as to the excuse for the late submission. Should the excuse for a late submission be deemed reasonable and sustained at trial or even on summary judgment, as a matter of law, then the carrier will have to pay the entire bill.
I suspect that the shrewd carrier, upon deciding to deny a bill for a 30-day rule or 45-day rule violation, would also adjust the bill from the standard medical management perspective. Accordingly, should the 30 or 45 day rule denial not hold, then a substantive defense could still be interposed.
