Timely denials necessary and a citation to Westchester/Lincoln

The Evolution of Timely Denial Requirements in No-Fault Insurance Law

The question of whether insurance companies must issue timely denials of claims based on IME or EUO no-shows represents one of the most contentious issues in New York no-fault insurance litigation. This requirement—that insurers must deny claims within statutory timeframes even when asserting no-show defenses—has been the subject of conflicting appellate decisions and inconsistent applications across different courts. The Appellate Term’s decision in Clinton Place Medical, P.C. v New York Central Mutual Fire Insurance Co. exemplifies the ongoing confusion surrounding this issue and raises important questions about which precedents courts should follow in 2014 and beyond.

At the heart of this dispute lies a fundamental question about the nature of no-show defenses. Are they procedural defenses that excuse compliance with normal statutory deadlines, or are they substantive defenses that must still be asserted through timely denials? The 2009 Westchester Medical Center v Lincoln General Insurance Co. decision held that timely denials are necessary even for no-show defenses, creating an additional burden on insurers seeking to rely on claimant non-compliance. However, subsequent decisions, particularly the 2011 Unitrin Advantage Insurance Co. v Bayshore Physical Therapy decision, cast doubt on Westchester/Lincoln’s continued validity.

This doctrinal uncertainty creates practical problems for both insurers and providers. Insurers must determine whether to issue denials when claimants fail to appear for IMEs or EUOs, risking preclusion if they guess wrong about whether timely denials are required. Providers must assess whether to challenge no-show defenses on timeliness grounds, recognizing that different courts may reach different conclusions about whether Westchester/Lincoln remains good law.

Case Background and the Timeliness Question

In Clinton Place Medical, a healthcare provider sued to recover no-fault benefits for medical services rendered to an eligible injured person. The insurance company moved for summary judgment dismissing the complaint based on the assignor’s failure to appear for duly scheduled Independent Medical Examinations. The insurer asserted that once the patient failed to comply with the IME requests, the insurer was entitled to deny the claims and discontinue payment regardless of whether those denials were issued within the normal statutory timeframes.

The provider opposed the motion, arguing among other grounds that the insurance company had failed to demonstrate that its denial of claim forms were timely issued after the assignor’s failure to appear for the IMEs. Under Westchester Medical Center v Lincoln General Insurance Co., the provider contended that even no-show defenses are subject to preclusion if the denial of claim forms are not issued within the statutory timeframes set forth in the no-fault regulations.

Jason Tenenbaum’s Analysis:

Clinton Place Med., P.C. v New York Cent. Mut. Fire Ins. Co., 2014 NY Slip Op 50954(U)(App. Term 2d Dept. 2014)

“A review of the record reveals that there is a question of fact as to whether defendant timely denied plaintiff’s claims after plaintiff’s assignor had failed to appear for duly scheduled independent medical examinations. Contrary to defendant’s contention, such a defense is subject to preclusion if defendant’s denial of claim forms were untimely (see Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 , lv denied 13 NY3d 714 ; see also Eastern Star Acupuncture, P.C. v American Tr. Ins. Co., 33 Misc 3d 141, 2011 NY Slip Op 52205 ; but see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559 , lv denied 17 NY3d 705 ).”

There are two cases from 2014 from the Appellate Division that state a timely disclaimer is a part of an insurance carriers prima facie case on an EUO/IME no-show matter. Why does this Court insist on citing the 2009 Westchester/Lincoln case. Much has happened in five years. And the Court in IDS left open the timliness argument by not reaching it. Perhaps, this Court could reach it as Westchester/Lincoln has been called into question. I don’t understand this Court sometimes.

Legal Significance and Doctrinal Confusion

The Appellate Term’s decision to rely on Westchester/Lincoln despite citing Unitrin’s contrary holding exemplifies the doctrinal uncertainty surrounding timely denial requirements for no-show defenses. By including “but see” signal before the Unitrin citation, the court acknowledged that its chosen precedent is subject to contrary authority, yet it proceeded to follow the older Westchester/Lincoln rule without explaining why that approach is superior.

The Westchester/Lincoln approach treats no-show defenses like any other defense subject to preclusion for untimely assertion. Under this view, when a claimant fails to appear for an IME or EUO, the insurer must still issue a denial of claim form within the statutory timeframes—typically 30 days from receipt of the claim or from the date additional verification was requested. Failure to meet these deadlines results in waiver or preclusion of the no-show defense, even though the insurer established that the claimant failed to comply with legitimate examination requests.

The Unitrin approach, by contrast, recognizes that no-show defenses operate differently from other defenses. When a claimant fails to cooperate with the claims investigation process by not appearing for examinations, the claim never ripens to the point where payment obligations are triggered. Under this theory, timely denial requirements should not apply because the insurer’s obligation to pay or deny within specific timeframes is contingent upon the claimant providing necessary cooperation.

Jason Tenenbaum’s frustration with the court’s continued reliance on Westchester/Lincoln reflects a broader practitioner concern about doctrinal consistency and predictability. When courts cite five-year-old precedent while acknowledging contrary authority without explaining why the older approach remains preferable, practitioners are left uncertain about what standards will apply to their cases.

Practical Implications for No-Fault Practice

For insurance companies handling no-fault claims, the Clinton Place decision counsels continued compliance with timely denial requirements even when asserting no-show defenses, at least in the Second Department. Until the appellate courts definitively resolve the conflict between Westchester/Lincoln and Unitrin, insurers should assume that courts may require timely denials for all defenses, including no-shows. This means implementing systems to quickly detect when claimants fail to appear for IMEs or EUOs and to generate and mail denial forms within statutory timeframes.

For healthcare providers challenging no-show defenses, this decision provides support for timeliness arguments but requires careful analysis of which precedent the court is likely to follow. Providers should investigate the timing of denial issuance and argue for preclusion when denials were issued long after no-shows occurred. Providers must also recognize that courts may follow Unitrin and reject timeliness challenges, requiring alternative grounds for defeating no-show defenses.

The decision also highlights the importance of discovery regarding the exact timing of all relevant events. Providers should seek documentation showing when IMEs or EUOs were scheduled, when no-shows occurred, when insurers first learned of the no-shows, and when denial forms were issued. This chronological evidence is essential for establishing whether denials were timely under whichever standard the court applies.

Related Articles

• Follow up verification issued >25 days too late is a loser
• EUO of a medical provider – untimely
• The backtracking of Unitrin
• No-show failed the Alrof test
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this 2014 post, New York courts have continued to develop the law regarding timely denials in EUO/IME non-appearance cases, potentially clarifying or modifying the precedential value of the Westchester/Lincoln decision cited. Practitioners should verify current caselaw and any regulatory changes to disclaimer timing requirements, as appellate decisions over the past decade may have further refined the standards for what constitutes a timely denial defense in no-fault insurance matters.