Another less than valid verification compliance affidavit suffices

New York’s no-fault insurance system requires healthcare providers to submit verification responses when insurance carriers request additional documentation to support claims. When disputes arise over whether these verifications were properly sent, courts must determine whether the evidence presented is sufficient to establish compliance. The case of Compas Med., P.C. v Praetorian Ins. Co. illustrates ongoing challenges in the standards applied to verification compliance affidavits.

This decision highlights a recurring pattern where appellate courts accept verification compliance affidavits that contain only generic language without specific details about what was actually mailed or when. The case demonstrates the tension between practical litigation needs and evidentiary standards in New York No-Fault Insurance Law disputes.

Case Background

Compas Medical, P.C. brought an action to recover no-fault insurance benefits from Praetorian Insurance Company. The insurer argued that the plaintiff’s claim was premature because the provider had failed to respond to verification requests seeking additional documentation to support the medical necessity and billing for services rendered. In response to Praetorian’s cross-motion for summary judgment, the plaintiff submitted an affidavit from its owner asserting that verification responses had been mailed to the defendant.

The central issue became whether this affidavit contained sufficient detail to raise a triable issue of fact regarding whether the requested verification materials were actually sent to the insurer. The lower court found the affidavit deficient, but the Appellate Term reversed, accepting the boilerplate language as sufficient to create a question of fact requiring trial.

Jason Tenenbaum’s Analysis

Compas Med., P.C. v Praetorian Ins. Co.,2015 NY Slip Op 51699(U)(App. Term 2d Dept. 2015)

However, in opposition to the cross motion, plaintiff submitted an affidavit from plaintiff’s owner, which affidavit was sufficient to give rise to a presumption that the requested verification had been mailed to, and received by, defendant (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 ). In light of the foregoing, there is a triable issue of fact as to whether this cause of action is premature (see Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co., 44 Misc 3d 59 ).

I read the affidavit. There is nothing except boilerplate about submitting verification responses to the carrier. Noteworthy, there is nothing provided showing wen the verification was mailed and what was mailed. Why? It never happened. I would hope after seeing the same affidavit, this Court would wake up and ask themselves why they are reversing close to 100 matters where judges found the plaintiff affidavit to be deficient. One day someone on the 15th floor will get it.

Legal Significance

This decision reflects a troubling pattern in the Second Department’s Appellate Term where generic, conclusory affidavits are deemed sufficient to create triable issues of fact in verification compliance disputes. The court’s reliance on Residential Holding Corp. v Scottsdale Insurance Co. to establish a presumption of mailing based on minimal testimony represents a low evidentiary threshold that contrasts sharply with the stringent personal knowledge requirements courts apply to insurance companies in other contexts, such as EUO no-show cases.

The ruling creates an asymmetry in evidentiary standards. When insurers assert defenses like EUO or IME no-shows, they must provide detailed proof including testimony from individuals with personal knowledge, specific dates and times, proof of mailing with proper addressing, and often contemporaneous documentation. However, when providers claim they mailed verification responses, appellate courts frequently accept bare assertions without corroborating detail.

This disparity raises concerns about whether the burden-shifting framework in no-fault litigation operates fairly. While the presumption of mailing upon proof of proper addressing serves legitimate purposes in avoiding endless litigation over routine correspondence, applying it without requiring any specificity about dates, contents, or mailing procedures effectively allows providers to defeat summary judgment through formulaic affidavits.

Practical Implications

For insurance companies, this decision underscores the difficulty of prevailing on verification non-receipt defenses even when providers submit affidavits lacking any meaningful detail. Insurers should consider implementing more robust verification tracking systems, including return receipt requests, electronic confirmation of receipt, and follow-up communications that create a paper trail demonstrating non-receipt.

For medical providers, the ruling provides a roadmap for defeating insurer summary judgment motions based on verification defenses. However, practitioners should be cautious about relying solely on boilerplate affidavits. While the Second Department’s Appellate Term has been lenient, trial courts retain discretion to find such affidavits insufficient, and stronger proof with specific dates and descriptions of documents mailed will always be more persuasive.

The broader lesson is that verification disputes often become battles of attrition rather than merits-based determinations. Both sides should recognize that these issues frequently create triable questions of fact, making early settlement or alternative dispute resolution more cost-effective than protracted litigation over whether generic correspondence was actually sent.

Key Takeaway

This case exemplifies a troubling trend where appellate courts accept boilerplate verification affidavits lacking specific details about mailing dates and contents. Despite the absence of concrete evidence that verification responses were actually sent, the court found sufficient grounds to create a triable issue of fact, potentially setting a low bar for verification compliance documentation.

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