Key Takeaway
New York court confirms that checking box #18 on denial forms adequately preserves fee schedule defenses in no-fault insurance disputes, providing clarity for insurers.
Understanding Fee Schedule Defense Preservation in No-Fault Insurance Claims
In New York’s no-fault insurance system, insurers must follow specific procedural requirements when denying claims to preserve their right to raise certain defenses later in litigation. One critical area involves fee schedule defenses, where insurers challenge whether medical providers are billing in accordance with statutory fee schedules. The question often arises: what constitutes sufficient notice to preserve these defenses?
The procedural requirements for claim denials are strictly enforced in New York courts. When insurers fail to properly preserve their defenses through adequate denial forms, they may find themselves unable to contest claims that could otherwise be successfully challenged. This creates significant financial exposure, particularly in cases involving policy coverage disputes where proper procedural compliance becomes even more crucial.
The Appellate Term’s recent decision provides important guidance on what constitutes adequate preservation of fee schedule defenses, specifically addressing whether simply checking a box on standard denial forms meets the legal threshold for preserving these defenses.
Jason Tenenbaum’s Analysis:
Shara Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co., 2013 NY Slip Op 50255(U)(App. Term 2d Dept. 2013)
“Contrary to plaintiff’s argument on appeal, defendant’s denial of claim forms were sufficient to preserve defendant’s fee schedule defense (see Arco Med. NY, P.C. v Lancer Ins. Co., 37 Misc 3d 136, 2012 NY Slip Op 52178 ).”
The Arco-Lancer case allowed for an EBT on “billing practices” because box #18 was checked.
Key Takeaway
The Appellate Term’s ruling establishes that checking box #18 on standard denial forms provides sufficient notice to preserve fee schedule defenses. This decision offers practical guidance for insurers, confirming that they need not provide elaborate explanations when the standardized checkbox system adequately communicates the basis for denial. The ruling also reinforces that such preservation can support discovery rights, including examinations before trial regarding billing practices.
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Legal Update (February 2026): Since this 2013 post, New York’s fee schedules and reimbursement rates have been subject to multiple regulatory amendments and updates. Additionally, procedural requirements for preserving fee schedule defenses may have evolved through subsequent case law and regulatory changes. Practitioners should verify current fee schedule provisions and denial form requirements, as the specific checkbox procedures discussed may no longer reflect current standards.
