45-day rule in action (or inaction)

Understanding the 45-Day Rule in No-Fault Insurance Claims

New York’s no-fault insurance system operates under strict timing requirements, with healthcare providers typically required to submit bills within 45 days of treatment. However, insurance companies cannot simply claim a bill was submitted late without proper documentation. A recent Appellate Term decision highlights the evidentiary standards required when insurers attempt to deny claims based on alleged late submissions.

The case demonstrates an important jurisdictional split between New York’s appellate departments regarding what constitutes sufficient proof of untimely billing submissions. While some courts have been more lenient with insurance company affidavits, this ruling establishes a higher bar for proving timing violations.

Jason Tenenbaum’s Analysis:

SMB Med. P.C. v Chubb Indem. Ins. Co., 2015 NY Slip Op 50719(U)(App. Term 1st Dept. 2015)

“Defendant failed to establish its entitlement to summary judgment dismissing the complaint based upon plaintiff’s alleged untimely submission of the claims beyond the applicable 45-day time limit (see 11 NYCRR 65-1.1). The affidavit of defendant’s claims adjuster failed to describe defendant’s “regular practices and procedures in retrieving, opening, and indexing its mail and in maintaining its files on existing claims”

The First Department (unlike Second Department precedent) requires some type of discussion in the affidavit to allow the affiant to reach the conclusion that the billing was untimely submitted. Just saying the billing was received on some day is insufficient.

Key Takeaway

Insurance companies cannot defeat no-fault claims simply by stating when they received billing documents. The First Department requires detailed affidavits explaining the insurer’s mail handling procedures and file maintenance practices. This procedural requirement protects healthcare providers from unfounded late notice claims and ensures proper due process in timing disputes.