Key Takeaway
New York Central Mutual tied up in Sound Shore case again - analysis of verification requests and procedural issues in no-fault insurance claims dispute between Mount Sinai Hospital and insurer.
This article is part of our ongoing additional verification coverage, with 92 published articles analyzing additional verification issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co., 2014 NY Slip Op 05779 (2d Dept. 2014)
(1) “In March 2011, Ana Rodriguez, who was insured under a policy of automobile insurance issued by the defendant, New York Central Mutual Fire Insurance Company (hereinafter New York Central), allegedly was injured in an automobile accident. In November 2011, she received treatment at a hospital facility of the plaintiff, Mount Sinai Hospital (hereinafter Mount Sinai). In early December 2011, a few days after Mount Sinai rendered this treatment, it sought payment for it. Mount Sinai’s third-party biller, The Outsource Group (hereinafter Outsource), sent a Form UB-04 and a letter requesting payment to New York Central. Twenty days after New York Central received the request, it requested verification of Mount Sinai’s claim. Approximately one week after New York Central sent the verification request, it received from Outsource more than 100 pages of documents, including records of Rodriguez’s treatment at Mount Sinai and various forms Rodriguez had completed there. New York Central did not request further verification. On January 27, 2012, less than 30 days after it received these records, New York Central issued a denial of the claim on a Form NF-10. The Form NF-10 was, in all substantial respects, complete.”
(2) “Two months later, on March 26, 2012, Mount Sinai, which was now represented by a different third-party biller, issued another request for payment of its bill for the treatment it had rendered to Rodriguez. This time, Mount Sinai’s third-party biller issued the request on a Form NF-5. New York Central ignored this request for payment, and, in May 2012, Mount Sinai, as assignee of Rodriguez, commenced this action seeking payment. Mount Sinai eventually moved for summary judgment on the complaint, and New York Central cross-moved for summary judgment dismissing [*2]the complaint. The Supreme Court denied Mount Sinai’s motion and granted New York Central’s cross motion. Mount Sinai appeals. We reverse.”
(3) “Here, in reliance on Sound Shore, Mount Sinai contends that its billing through Outsource in December 2011 on a Form UB-04 did not commence the 30-day period in which New York Central was required to pay, deny, or request verification of Mount Sinai’s claim. Instead, Mount Sinai contends, the 30-day period commenced in March 2012, when Mount Sinai submitted a billing request on a Form NF-5. In effect, Mount Sinai contends, New York Central’s denial of claim in January 2012 did not deny anything; there was no claim submitted in December to deny.”
My opinion is that this is far fetched. Everyone knows no-fault is a game of form over substance. Some call it the game of gotcha. Recall Justice McKeon’s concurrence in Lenox Hill v. Tristate? I am baffled how a re-bill triggered a new 30-day pay or deny period, when the App. Div. has previously said this was not the case. So, through magic of form NF-5, a new 30-day pay or deny period materialized?
In St. Vincent v. Countrywide 7 years ago, this Court stated that a follow-up verification was issued on day 30 (not 31-40) was sufficient to preserve the tolling because, in essence, the carrier should not be penalized for proactive claims handling. The Court reversed the Appellate Term on the fact, the law and in the interest of justice. Now 7 years later, this Court through Sound Shore and now Mount Sinai has given the Henig gang a free pass on logic for “strict compliance” with how this Court perceives the regulations should be interpreted.
This case cries for a trip to Albany. The only catch, of course, is why was the original bill denied? Assuming the Court of Appeals said this is an injustice and allows the original UB-04 “under the peculiar facts of this case” to act as the NF-5, what is the substantive defense to this hospital bill?
Finally, I would be remiss if I did not express the first thing on my mind when I read this case was, but why the heck did NYCM not address the second submission. That is baffling.
Related Articles
- Understanding verification request procedures and mailing requirements
- The 150-day verification rule in New York no-fault insurance
- When technical verification requirements override common sense
- Procedural fairness issues in no-fault insurance litigation
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2014 decision, New York’s no-fault regulations have undergone several amendments, particularly regarding verification procedures, Form NF-10 requirements, and third-party billing protocols. Practitioners should verify current provisions of 11 NYCRR Part 65 and any updates to statutory denial procedures that may affect the timing and documentation standards discussed in this case.
Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Additional Verification in No-Fault Claims
Under New York's no-fault regulations, insurers may request additional verification of a claim within specified time limits. The timeliness, scope, and reasonableness of verification requests — and the consequences of a claimant's failure to respond — are among the most litigated issues in no-fault practice. These articles examine the regulatory framework for verification requests, court decisions on compliance, and the interplay between verification delays and claim determination deadlines.
92 published articles in Additional Verification
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Oct 13, 2016Follow the NF-5
Mount Sinai v Dust Tr. case analysis: verification requests sent before receiving NF-5 forms don't toll the 30-day payment period under NY no-fault law.
May 26, 2014The Verification Process in No-Fault Insurance: When Technical Requirements Override Common Sense
Expert analysis of Exoto v Progressive Insurance on NF-3 verification requirements. Learn to avoid technical rejections in Long Island and NYC. Call 516-750-0595 for help.
Mar 10, 2011The additional verification paradigm (again)
New York no-fault case clarifies burden of proof in additional verification disputes, showing how procedural missteps can doom otherwise valid claims.
Sep 4, 2019Common Questions
Frequently Asked Questions
What is additional verification in no-fault insurance?
Additional verification is a request by the insurer for more information to process a no-fault claim, authorized under 11 NYCRR §65-3.5. When the insurer sends a verification request, the 30-day clock for claim processing is tolled (paused) until the requested information is received. This is a common insurer tactic to delay payment — but the verification request must be timely and relevant to be valid.
How long does an insurer have to request additional verification?
Under the no-fault regulations, the insurer must request initial verification within 15 business days of receiving the claim. Follow-up verification requests must be made within 10 business days of receiving a response to the prior request. If the insurer fails to meet these deadlines, the verification request is invalid and cannot be used to toll the claim processing period.
What types of additional verification can a no-fault insurer request?
Under 11 NYCRR §65-3.5, insurers may request medical records, provider licensing documentation, proof of treatment rendered, tax returns or financial records (in certain fraud investigations), authorization for release of medical records, and signed NF-3 verification forms. The verification request must be relevant to the claim and not overly burdensome. Requests for information not reasonably related to claim processing may be challenged as improper.
What happens if I don't respond to a no-fault verification request?
Failure to respond to a timely and proper verification request can result in denial of your no-fault claim. Under 11 NYCRR §65-3.5(o), if the requested verification is not provided within 120 calendar days of the initial request, the claim is deemed denied. The 120-day period runs from the date of the original request. However, if the verification request itself was untimely or improper, the denial based on non-response may be challenged.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a additional verification matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.