The reason proffered by plaintiff was insufficient

Case Background

The case of Leica Supply, Inc. v American Tr. Ins. Co. centers on a healthcare provider’s attempt to justify late submission of no-fault insurance claims. The medical services were rendered between February 14, 2008, and March 7, 2008, but the claims were not submitted to the correct insurer until June 25, 2008—well beyond the mandatory 45-day billing deadline established by Insurance Department regulations.

The provider’s explanation for the delay involved an initial submission to the Motor Vehicle Accident Indemnification Corporation (MVAIC) on March 24, 2008, based on the provider’s assertion that the identity of the actual insurer was not apparent from the documentation available at the time. Only after MVAIC identified American Trust Insurance Company (ATIC) as the proper insurer did the provider submit the bills to the defendant carrier, accompanied by an explanation for the tardiness.

This sequence of events raised a fundamental question: Does confusion about insurer identity constitute sufficient reasonable justification for late claim submission under the regulatory framework?

Jason Tenenbaum’s Analysis:

Leica Supply, Inc. v American Tr. Ins. Co., 2013 NY Slip Op 50711(U)(App. Term 2d Dept. 2013)

“plaintiff had submitted its claims to defendant more than 45 days after the date the services had been rendered to plaintiff’s assignor (see Insurance Department Regulations § 65-1.1). Defendant’s denial of claim form adequately advised plaintiff of the basis for the denial, and it further advised plaintiff that the late submission of the claim would be excused if plaintiff provided a reasonable justification for the lateness (see Insurance Department Regulations § 65-3.3 ). We find that the reason proffered by plaintiff was insufficient.”

Since this is my case, here is the insufficiently proffered reason.

The bill here is for services on 2/14/08-3/7/08. Plaintiff provided proof that it mailed the bill to MVAIC on 3/24/08. This was through a letter with a mailing ledger and an affidavit from the billing manager. What was the reason the bill was sent to MVAIC? ” TIC was not known or indicated on the documents to be the insurer. “Only MVAIC advised that ATIC was, indeed, the insurer. Copes are attached. We never heard again from the examiner” The bill was then mailed to Defendant on 6/25/08 with explanation of tardiness.

Appellate Term found this to be an insufficient excuse. Interesting.

Legal Significance

The Appellate Term’s decision in Leica Supply establishes important boundaries around what constitutes “reasonable justification” under Insurance Department Regulations § 65-3.3. While the regulation provides a safety valve for providers who miss the 45-day deadline, courts have consistently held that not every explanation will suffice.

The court’s ruling suggests that healthcare providers bear the responsibility for conducting adequate due diligence to identify the correct insurer before the 45-day period expires. The fact that plaintiff submitted proof of mailing to MVAIC—including a letter with mailing ledger and an affidavit from the billing manager—demonstrated some organizational effort, but did not overcome the fundamental problem: the provider could have determined the proper insurer through other means within the regulatory timeframe.

This decision reinforces the principle that confusion about insurer identity, standing alone, does not automatically excuse late submission. Providers are expected to utilize available resources to identify the correct carrier, including reviewing police reports, contacting the injured party directly, or conducting insurer database searches. The regulatory scheme contemplates that providers will take affirmative steps to identify insurers promptly, rather than defaulting to MVAIC submissions as a first resort.

The court’s emphasis on the adequacy of the denial form notice also highlights procedural requirements. The defendant’s denial form properly advised plaintiff of both the basis for denial and the opportunity to provide reasonable justification for lateness. When such notice is properly given, the burden shifts entirely to the provider to present a compelling explanation.

Practical Implications

For healthcare providers practicing in New York’s no-fault system, Leica Supply serves as a cautionary tale about the limitations of claiming insurer confusion. Several practical lessons emerge from this decision:

First, providers should implement systematic procedures for identifying insurers at the point of service. This includes obtaining complete insurance information directly from patients, verifying coverage through real-time eligibility systems where available, and documenting all efforts to identify the proper carrier. Relying solely on documentation that may be incomplete or unclear creates unnecessary risk.

Second, when insurer identity remains genuinely unclear after reasonable investigation, providers should consider dual submissions—to both MVAIC and any potentially applicable carrier—within the 45-day window. While this may create some administrative burden, it provides protection against exactly the type of late submission problem presented in Leica Supply.

Third, when providers do submit claims late and receive denial forms offering the opportunity to justify the delay, the response must be specific, well-documented, and legally persuasive. Generic explanations about confusion or administrative difficulties will likely fail. The justification should detail concrete steps taken to identify the insurer, explain why those steps were unsuccessful within 45 days, and demonstrate that the provider acted with reasonable diligence throughout the process.

Finally, this case underscores the importance of understanding that MVAIC serves as a payer of last resort, not as a convenient receptacle for claims when insurer identity is uncertain. Courts will scrutinize whether providers appropriately exhausted other avenues for identifying the correct carrier before resorting to MVAIC submissions.

Related Articles

• MVAIC 45-day rule timing requirements and real problems
• What happens after the 45-day deadline passes
• Provider requirements for explaining untimely bill submissions
• 45-day rule cases involving insufficiency of justification
• Triable issues of fact in 45-day rule disputes

Legal Update (February 2026): Since this 2013 decision, the Insurance Department regulations governing no-fault billing submissions and excuse provisions under §§ 65-1.1 and 65-3.3 may have been amended, and the standards for evaluating “reasonable justification” for late submissions could have evolved through subsequent regulatory updates or case law interpretations. Practitioners should verify current regulatory provisions and recent appellate decisions when assessing acceptable excuses for untimely claim submissions.