Key Takeaway
New York's Second Department confirms that no-fault insurers have no obligation to pay or deny claims until all demanded verification is properly submitted by providers.
Understanding Verification Requirements in No-Fault Insurance Claims
No-fault insurance claims in New York operate under a structured system where healthcare providers must submit specific documentation to support their reimbursement requests. One critical aspect of this process involves verification requirements – additional documentation that insurers can demand to validate claims before making payment decisions.
The timing of when insurers must respond to claims becomes crucial when additional verification is requested. Healthcare providers often wonder whether they can immediately file lawsuits when insurers fail to respond within standard timeframes, but the legal landscape is more nuanced than it might initially appear.
This intersection of verification requirements and lawsuit timing has significant implications for both healthcare providers seeking reimbursement and insurers managing their claim obligations under New York No-Fault Insurance Law. The Second Department’s decision in Westchester Medical Center provides important clarity on this procedural requirement.
Understanding when verification obligations are truly complete – and when the clock starts ticking for insurer response obligations – can mean the difference between a successful claim and a premature lawsuit that gets dismissed on procedural grounds.
Jason Tenenbaum’s Analysis:
Westchester Med. Ctr. v Country Wide Ins. Co., 2011 NY Slip Op 03838 (2d Dept. 2011)
“The defendant was not obligated to pay or deny the claim until all demanded verification was provided by the plaintiff (see St. Barnabas Hosp. v American Tr. Ins. Co., 57 AD3d at 518).”
I do not see anything here about reasonable or necessary, although there is Appellate Term authority that raises this issue.
Key Takeaway
The Second Department’s ruling establishes a clear procedural requirement: insurers have no legal obligation to pay or deny no-fault claims until healthcare providers have submitted all requested verification materials. This means that filing lawsuits before completing verification requirements may be premature and subject to dismissal. Providers should ensure they have properly addressed all verification requests before pursuing legal action for unpaid claims.
Legal Update (February 2026): Since this 2011 post, New York’s no-fault insurance regulations and verification procedures may have been modified through regulatory amendments, updated fee schedules, or changes to procedural requirements under 11 NYCRR Part 65. Practitioners should verify current verification submission requirements, timing provisions, and lawsuit prerequisites under the most recent regulatory framework before relying on the analysis presented here.
