Understanding No-Fault Insurance Claim Denials: Key Lessons from Five Boro Psychological Services Case

Understanding No-Fault Insurance Claim Denials: Key Lessons from Five Boro Psychological Services Case

When your no-fault insurance claim is denied, understanding the legal requirements for proper denial procedures can make the difference between receiving the benefits you deserve and facing an uphill battle in court. For healthcare providers and accident victims throughout Long Island and New York City, a recent Appellate Term decision provides crucial insights into how denial of claim forms can be used as evidence and what documentation requirements apply in no-fault litigation.

The Five Boro Psychological Services Case: A Detailed Analysis

Five Boro Psychological Servs., P.C. v Progressive Northeastern Ins. Co.

2011 NY Slip Op 51528(U)

Decided on August 4, 2011

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on August 4, 2011

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., WESTON and STEINHARDT, JJ
2009-2456 K C.

Five Boro Psychological Services, P.C. as Assignee of GEORGETTE BECKVERMIT, Appellant,

**

against

**

Progressive Northeastern Insurance Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Dawn Marie Jimenez, J.), entered September 21, 2009. The order granted defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order granting defendant’s motion for summary judgment dismissing the complaint.

Plaintiff argues on appeal that, because defendant failed to attach a copy of the bill at issue in this case to its motion papers, the Civil Court could not have been able to identify the bill at issue and, thus, defendant’s motion should have been denied. This contention is without merit. The complaint in this matter identified the sole bill at issue (see CPLR 3013), and defendant attached the complaint to its motion papers as required by CPLR 3212 (b). Accordingly, there could not have been any question as to the identity of the bill which is the subject of this action.

Next, plaintiff correctly argues that defendant could not rely on defendant’s denial of claim forms “for the purposes of asserting the information contained within them,” such as “the dates of services, the services performed, the fees charged per service provided, etc.” However, defendant was not relying on them for that purpose. It is plaintiff’s burden, not defendant’s, to prove the elements of plaintiff’s cause of action. Defendant submitted the denial of claim form to show that it was sent and that the claim was therefore denied (see Five Boro Psychological Servs., P.C. v Progressive Northeastern Ins. Co., 27 Misc 3d 141, 2010 NY Slip Op 50991 ; Quality Health Prods., Inc. v NY Cent. Mut. Fire [*2]Ins. Co., 27 Misc 3d 141, 2010 NY Slip Op 50990 ). Since defendant did not submit the denial of claim form for a hearsay purpose, defendant was not required to lay a CPLR 4518 foundation for its admissibility (see Five Boro Psychological Servs., P.C., 27 Misc 3d 141, 2010 NY Slip Op 50991; Quality Health Prods., Inc., 27 Misc 3d 141, 2010 NY Slip Op 50990).

In view of the foregoing, and as plaintiff’s remaining contentions similarly lack merit (see Alfa Med. Supplies v Progressive Northeastern Ins. Co., 29 Misc 3d 128, 2010 NY Slip Op 51733 ), the order is affirmed.

Understanding No-Fault Insurance Claim Denials in New York

No-fault insurance is designed to provide quick access to medical benefits for accident victims, but claim denials remain a significant challenge for healthcare providers and patients throughout Long Island, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. The Five Boro Psychological Services case illustrates several key principles that affect how denial cases are litigated and what evidence can be used to support or challenge claim denials.

The Importance of Proper Documentation

One of the most critical aspects of any no-fault case is proper documentation. The Five Boro case demonstrates that courts expect all parties to follow procedural requirements carefully. For healthcare providers treating accident victims in Nassau County, Suffolk County, and New York City, this means:

• Ensuring all bills are properly identified and documented
• Maintaining complete records of all communications with insurance carriers
• Understanding the difference between procedural compliance and substantive evidence
• Working with experienced no-fault attorneys who understand evidentiary requirements

Burden of Proof in No-Fault Claims

The court’s decision reinforces a fundamental principle of no-fault litigation: the burden of proof lies with the healthcare provider or patient seeking benefits. Insurance companies do not have to prove that services were not provided or that charges are unreasonable. Instead, they must only demonstrate that they properly denied the claim according to statutory requirements.

This burden allocation has significant implications for accident victims and their healthcare providers. It means that plaintiffs must be prepared to prove:

• The services were medically necessary and related to the accident
• The charges are reasonable and customary
• All procedural requirements were met
• The denial was improper or unjustified

Evidence Rules in No-Fault Litigation

Denial of Claim Forms: Admissibility and Use

The Five Boro case clarifies an important distinction about how denial of claim forms can be used in litigation. Insurance companies can use these forms to prove that a denial was sent, but they cannot rely on the contents of the forms to prove substantive facts about the services provided or the reasonableness of charges.

This distinction is crucial for several reasons:

• Non-hearsay use: When used only to show that a denial was sent, the forms don’t require a CPLR 4518 foundation
• Limited evidentiary value: The forms cannot be used to prove details about medical services or billing
• Strategic implications: Providers and their attorneys must be prepared to prove their case independently of information in denial forms

Frequently Asked Questions

Q: Can insurance companies use denial forms as evidence against my claim?

A: Insurance companies can use denial forms to prove that they sent a denial, but they cannot use the content of these forms to prove substantive facts about your medical treatment or the reasonableness of charges.

Q: What happens if my healthcare provider didn’t attach my bill to their court papers?

A: As long as the bill is clearly identified in the complaint and the complaint is attached to the motion papers, the absence of the actual bill may not be fatal to the case.

Q: Who has the burden of proof in a no-fault denial case?

A: The healthcare provider or patient challenging the denial has the burden of proving that the services were necessary, reasonable, and properly billed. The insurance company only needs to prove that it properly denied the claim.

Q: What should I do if my no-fault claim is denied?

A: Contact an experienced no-fault attorney immediately. Time limits apply to challenging denials, and the strength of your case often depends on how quickly you respond to the denial.

Expert Legal Representation for No-Fault Denials

If your no-fault insurance claim has been denied or you’re facing challenges in recovering benefits for accident-related medical treatment, don’t address the complex legal system alone. The experienced attorneys at the Law Office of Jason Tenenbaum understand the intricacies of no-fault law and the evidentiary requirements highlighted in cases like Five Boro Psychological Services.

Whether you’re a healthcare provider dealing with claim denials or an accident victim whose treatment isn’t being covered, our team has the knowledge and experience to protect your rights. We serve clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island.

Contact us today at 516-750-0595 for a free consultation. Our experienced no-fault attorneys will review your denial, explain your rights, and develop a strategy to challenge improper denials or defend against insurance company tactics. We understand how decisions like Five Boro Psychological Services affect your case and can help you address the complex world of New York no-fault litigation.

Time is critical in no-fault cases, especially when dealing with denials. Call 516-750-0595 now to speak with a knowledgeable attorney who can help you understand your options and fight for the benefits you deserve. Don’t let insurance company denials prevent you from receiving the medical care and compensation you need to recover from your accident injuries.

Related Articles

• Understanding how St. Barnabus v. Allstate shaped no-fault defense strategy
• How claim representative affidavits can cure NF-10 form inaccuracies
• Why failure to object to denial form deficiencies waives your rights
• When materiality of mistakes renders insurance claim denials invalid
• Hidden complexities in no-fault law revealed in Ortho Med Supply v Mercury

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Legal Update (February 2026): The regulatory framework governing no-fault insurance claim denials, including preservation requirements for NF-10 forms and procedural standards established in this 2011 case, may have been significantly modified through regulatory amendments and updated Insurance Department guidelines since this post’s publication. Practitioners handling no-fault claims should verify current preservation of defenses requirements and documentation standards, as these provisions are subject to periodic regulatory revision.