New York Central Mutual has got tied up in Sound Shore (again?)

An insurer’s earlier denial did not dispose of the later NF-5 claim in Mount Sinai Hospital v New York Central Mutual Fire Insurance Co., decided August 13, 2014. The Second Department held that the first, defective UB-04 submission did not start the 30-day claim clock. The later NF-5 did—and the insurer did not act on it.

Historical note: Mount Sinai applied Sound Shore (2013) to a defective UB-04 submission followed by an NF-5. It did not establish that every rebill restarts a claim clock. The distinction between prescribed hospital forms and other verification remains in 11 NYCRR 65-3.5(f)–(g).

Last reviewed: September 2026.

Jason’s original criticism of that result is preserved below. The court’s holding and the criticism should be read separately. The decision did not accept the insurer’s argument that the later submission was simply a rebill of a claim already denied.

The two submissions

The hospital treated its assignor in November 2011. In early December, its biller sent a UB-04 and a payment-request letter. The insurer sought verification 20 days after receiving that submission and then received more than 100 pages of records and forms about a week later.

The insurer did not request further verification. On January 27, 2012, less than 30 days after those records arrived, it issued an NF-10 denial that was substantially complete.

The hospital then used a different biller. On March 26, 2012, that biller submitted an NF-5 for the treatment. The insurer ignored the new submission. The hospital sued and the parties each sought summary judgment.

Supreme Court ruled for the insurer. The Appellate Division reversed, granting the hospital’s motion and denying the insurer’s cross-motion.

Why the NF-5 mattered

The court relied on Sound Shore Medical Center v New York Central Mutual, 106 AD3d 157. That earlier decision rejected treating the UB-04 before it as the functional equivalent of a completed NF-5. The forms did not supply the same claim information.

In Mount Sinai, the court held that the claim period began with the March NF-5, which supplied the information needed. It treated the January denial of the defective December submission as ineffective against that later claim.

This is a claim-form sufficiency ruling, not a general right to restart deadlines by changing billers or resending the same completed claim. The insurer raised the rebilling argument; the court rejected it because the earlier defective submission had not started the clock in the first place.

What the regulation distinguishes

Under 11 NYCRR 65-3.5(f), an insurer must accept an alternative proof-of-claim form containing substantially the same information, but may require the prescribed application, provider-treatment verification and hospital facility forms.

Section 65-3.5(g) separately requires acceptance of a completed NF-5, or the specified NF-5 and billing-form combination supplying the requested information, in lieu of the application and hospital-treatment verification forms. A UB-04 alone is not automatically equivalent simply because it lists charges.

For a form dispute, examine what was actually supplied. Sound Shore identified missing claim information in its own record; that does not authorize assuming every alternative submission is deficient without reading it.

Do not confuse the claim clock with accident notice

This opinion concerns the hospital’s proof of claim and the insurer’s response to it. Accident notice, submission of medical-service proof and additional-verification responses are separate steps.

The Court of Appeals’ Viviane Etienne decision distinguishes the ordinary 30-day accident-notice requirement from the 45-day period for submitting proof of medical services. Neither should be rewritten as a single universal notice deadline. Applicable exceptions and the claim’s governing policy and regulation still require review.

For this historical file, the decisive point was that the insurer did not pay, deny or request verification of the effective March claim within the applicable period. The appellate court did not need to decide every other contention the hospital raised.

The useful question in Jason’s criticism

Jason asked why the insurer did not address the second submission. That question remains practically important even for a reader who disagrees with the court’s treatment of the first bill.

When a later form arrives, compare it with the earlier submission. Identify whether it adds prescribed claim information, corrects a defect or merely repeats a completed claim. Do not treat the answer as self-evident from the billing provider’s name or the fact that the services match.

The original discussion also asks what substantive defense the insurer had to the hospital bill. The published opinion does not resolve that medical or coverage question. The current explanation therefore does not invent a denial basis or describe a later appeal outcome that has not been established here.

Jason’s original commentary

The original comments below are retained as historical commentary. The case-specific corrections and later developments are explained above.

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.

Connect to the Encyclopedia

Start with the no-fault verification hub and 2026 Chapa update for the governing framework and case directory. Related case notes:

• NYU Hospital-Tisch: final response dates and timely denial.
• Infinity’s 2008 decision and its reversal.
• Bronx Acupuncture: By Report documentation.
• Excel Surgery: answering the specific requested items.
• The 2009 Infinity appeal: from pending issue to decision.
• Great Health Care: evidence that verification was mailed.

For review of a particular no-fault verification dispute, request a Free Case Review. Keep the requests, responses and relevant claim dates available for that review.