Key Takeaway
Court ruling shows insurance companies lose IME defense rights when they fail to deny claims within mandatory 30-day period under NY no-fault regulations.
Insurance Companies Must Act Quickly on No-Fault Claims or Lose Defense Rights
Under New York’s no-fault insurance regulations, insurance companies face strict deadlines when processing medical claims. When insurers fail to meet these deadlines, they can lose important defense rights - including the ability to deny claims based on a patient’s failure to appear for Independent Medical Examinations (IMEs) or Examinations Under Oath (EUOs).
This principle was reinforced in a recent Appellate Term decision that demonstrates how procedural requirements in New York No-Fault Insurance Law can significantly impact claim outcomes. The case highlights the critical importance of the 30-day claim determination period established under New York regulations.
Jason Tenenbaum’s Analysis:
Compas Med., P.C. v Praetorian Ins. Co., 2015 NY Slip Op 51667(U)(App. Term 2d Dept. 2015)
“However, with respect to the third cause of action, the record establishes that the claim at issue was not denied within 30 days of its receipt (see 11 NYCRR 65-3.8 ) and defendant did not demonstrate that the 30-day claim determination period (see 11 NYCRR 65-3.8) had been tolled. As a result, since defendant is precluded from asserting, with respect to this claim, its defense that plaintiff’s assignor had failed to appear for the duly scheduled IMEs and EUOs (see Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 ), plaintiff is entitled to summary judgment upon its third cause of action.”
Key Takeaway
This decision reinforces that insurance companies operating under New York’s no-fault system must strictly adhere to regulatory timelines. When an insurer fails to deny a claim within 30 days and cannot prove the deadline was properly tolled, they forfeit their right to raise common defenses like IME no-shows. This creates a powerful tool for medical providers seeking payment for covered services.
Legal Update (February 2026): Since this 2015 post, New York’s no-fault insurance regulations under 11 NYCRR Part 65 have undergone multiple amendments, including potential modifications to claim processing timeframes, IME scheduling requirements, and insurer defense preservation procedures. The regulatory framework governing the 30-day claim determination period referenced in section 65-3.8 may have been revised through subsequent rulemaking. Practitioners should verify current provisions of 11 NYCRR 65-3.8 and related sections to ensure compliance with the most recent regulatory requirements.
