Key Takeaway
New York court ruling demonstrates how insurance companies can successfully defend no-fault claims when healthcare providers fail to respond to verification requests.
No-fault insurance disputes often hinge on procedural requirements that both insurers and healthcare providers must follow. When insurance companies request additional verification of medical services, providers have specific obligations to respond. The failure to meet these verification requirements can have significant consequences for reimbursement claims, as demonstrated in recent New York appellate decisions.
Understanding the interplay between additional verification requirements and procedural defenses is crucial for healthcare providers seeking reimbursement. Courts consistently examine whether insurers properly requested verification and whether providers adequately responded to such requests.
Jason Tenenbaum’s Analysis:
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 2013 NY Slip Op 50199(U)(App. Term 2d Dept. 2013)
“With respect to the claims seeking the sums of $1,109.05, $3,227.26 and $1,153, the affidavit by defendant’s no-fault litigation supervisor established that the initial and follow-up verification requests for additional verification had been timely mailed (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16) and that plaintiff had failed to provide all of the requested additional verification”
There was a discussion regarding the failure to establish as a matter of law the fee schedule defense. I suspect it was a code reduction that was not backed up with an expert affidavit. Juast Keycite Rogy Medical v. Mercury…
See also: Viviane Etienne Med. Care, P.C. v GEICO Gen. Ins. Co., 2013 NY Slip Op 50196(U)(App. Term 2d Dept. 2013)
Key Takeaway
This case illustrates the importance of responding to verification requests in New York no-fault insurance claims. When insurers properly mail verification requests and providers fail to respond completely, courts will uphold claim denials. The decision also highlights potential issues with fee schedule defenses that lack proper expert support.
Legal Update (February 2026): Since this post’s publication in 2013, New York’s no-fault insurance regulations, including fee schedules, verification procedures, and reimbursement requirements, may have been subject to regulatory amendments or updates. The specific fee amounts referenced and procedural requirements for additional verification requests discussed may no longer reflect current provisions. Practitioners should verify current regulations and recent appellate decisions when handling verification disputes and reimbursement claims.
