Key Takeaway
New York court rules that denial letters with EOB forms adequately preserve fee schedule defenses in no-fault insurance disputes, even without explicit notice requirements.
Understanding Fee Schedule Defense Preservation in No-Fault Cases
No-fault insurance disputes often hinge on whether insurers properly preserve their defenses when denying claims. The fee schedule defense—which allows insurers to limit payments based on statutory fee schedules—is particularly important in New York No-Fault Insurance Law cases. Healthcare providers frequently challenge whether insurers gave adequate notice of their intent to rely on fee schedule limitations when partially paying claims.
The Appellate Term’s decision in W.H.O. Acupuncture, P.C. v AIG Auto Ins. addresses a fundamental question: what level of notice must an insurer provide to preserve its fee schedule defense? This case is especially relevant for acupuncture providers dealing with CPT Code 97813 and 97814 billing disputes, where fee schedule limitations frequently come into play.
Jason Tenenbaum’s Analysis:
W.H.O. Acupuncture, P.C. v AIG Auto Ins., 2012 NY Slip Op 50755(U)(App. Term 2d Dept. 2012)
“Contrary to plaintiff’s sole contention, defendant’s denial of claim forms and the accompanying explanation of benefit forms were sufficient to apprise plaintiff that defendant was partially paying and partially denying its bills on the ground that the unpaid portion exceeded the amount permitted by the workers’ compensation fee schedule. Accordingly, the order is affirmed”
I have to wonder if a “you failed to explicitly ask for judicial notice” argument would have worked? It seems to be the flavor of the year at this Court.
Key Takeaway
The Appellate Term ruled that standard denial letters combined with explanation of benefits forms provide adequate notice to preserve fee schedule defenses. This decision establishes that insurers don’t need to provide elaborate explanations—basic EOB documentation indicating partial payment due to fee schedule limitations is sufficient notice under the law.
Legal Update (February 2026): Since this 2012 post, New York’s no-fault fee schedules and reimbursement methodology have undergone significant revisions, including updates to workers’ compensation fee schedule references and procedural requirements for preserving fee schedule defenses. Practitioners should verify current statutory provisions and recent appellate decisions regarding adequate notice requirements for fee schedule limitations.
