Tolling for an IME or EUO

New York’s no-fault insurance system imposes strict 30-day deadlines for insurers to pay or deny claims, creating bright-line rules designed to ensure prompt payment to medical providers and injured parties. Insurance Regulation 11 NYCRR § 65-3.8 establishes this framework, requiring carriers to process claims expeditiously and communicate decisions within statutorily mandated timeframes. However, carriers frequently require additional information before making coverage determinations, including scheduling independent medical examinations or examinations under oath to evaluate claim legitimacy, medical necessity, or fraud concerns.

The tension between carriers’ need for reasonable claim investigation and the statutory 30-day payment deadline presents recurring litigation issues. Carriers have long maintained that properly scheduling IMEs or EUOs tolls the 30-day period, suspending payment obligations until the examination occurs or the claimant fails to appear. Providers and injured parties, conversely, argue that mere examination scheduling without other procedural compliance fails to toll payment deadlines, rendering claims overdue when carriers miss the 30-day window despite pending examinations.

The critical question becomes: what specific documentation must carriers submit to courts to establish that IME or EUO scheduling effectively tolled the statutory payment period? Courts addressing this issue determine whether generic bill delay letters referencing pending examinations suffice, or whether carriers must produce the actual examination scheduling correspondence demonstrating proper notice, timing, and procedural compliance with regulatory requirements.

Case Background

In PR Medical, P.C. v Praetorian Insurance Co., the medical provider plaintiff sought payment for $2,005.25 in outstanding no-fault claims. The plaintiff established its prima facie case by demonstrating that the claims were neither denied nor paid within the prescribed 30-day statutory period. Faced with this showing, the burden shifted to the defendant carrier to raise triable issues regarding why the claims remained unpaid.

Praetorian Insurance Company defended by arguing that the 30-day payment period was tolled because it had scheduled independent medical examinations of the plaintiff’s assignor before the deadline expired. The carrier submitted a letter stating, in essence, that payment was delayed pending IMEs. Based on this correspondence, the carrier contended it had satisfied its burden to demonstrate tolling, creating a factual dispute precluding summary judgment.

The Civil Court accepted the carrier’s argument and denied the plaintiff’s summary judgment motion, concluding that the bill delay letter referencing pending IMEs sufficiently raised triable issues about whether the statutory period was tolled. On appeal, the Appellate Term reexamined whether the carrier’s submissions met the evidentiary burden to establish tolling or whether additional documentation was required.

PR Med., P.C. v Praetorian Ins. Co., 2016 NY Slip Op 50338(U)(App. Term 1st Dept. 2016)

(1) Prima facie case: “Turning to the merits, plaintiff established prima facie that its no-fault claims in the amount of $2,005.25 were overdue, since they were not “denied or paid” within the prescribed 30-day period”

(2)“Contrary to Civil Court’s determination, defendant’s letter stating, in essence, that payment was delayed pending independent medical examinations (IMEs) of plaintiff’s assignor did not serve to toll the 30-day statutory period (id.). Nor has defendant otherwise raised a triable issue as to whether the 30-day period was tolled by verification requests that preceded its receipt of the underlying claims”

If you are trying to decipher this one, I think I might have the answer here. In order to toll the time to pay or deny when a bill is delayed for an IME or EUO, the carrier besides putting in the bill delay must also put in the submissions the EUO or IME scheduling letters. That was not done here. For may of us, just keep an eye on this – I just instructed my office to keep an eye on this subtle issue. It has happened to all of us at some point.

Legal Significance

The Appellate Term’s holding establishes a critical evidentiary requirement for carriers asserting tolling based on scheduled examinations. Generic bill delay letters stating that payment is pending IMEs or EUOs do not, standing alone, create triable issues regarding tolling. Rather, carriers must submit the actual examination scheduling correspondence to establish that tolling occurred. This requirement reflects several important policy considerations underlying no-fault claim processing.

First, requiring production of scheduling letters ensures that examinations were actually scheduled rather than merely contemplated. Carriers cannot defeat summary judgment simply by claiming they intended to schedule examinations—they must prove they took concrete steps to schedule examinations with specific dates, times, and locations. This prevents carriers from manufacturing tolling defenses by making unsupported assertions about examinations that never actually occurred.

Second, examination scheduling letters contain critical information demonstrating regulatory compliance. No-fault regulations impose specific requirements for IME and EUO notices, including minimum advance notice periods, proper address usage, and clear identification of examination purposes. By requiring production of actual scheduling letters, courts can verify that carriers complied with these regulatory prerequisites to valid tolling rather than accepting carriers’ conclusory assertions of compliance.

Third, the timing reflected in scheduling letters determines whether tolling actually occurred within the 30-day period. Carriers who schedule examinations on day 31 or later cannot claim those examinations tolled the initial 30-day period. Only scheduling letters demonstrating that examination requests went out before the 30-day deadline expires can establish tolling of that period. Without the scheduling letters themselves, courts cannot verify this critical timing element.

The decision also addresses carriers’ attempts to establish tolling through verification requests preceding claim receipt. The court rejected this argument, recognizing that verification requests sent before carriers receive bills cannot toll periods that have not yet commenced. This prevents carriers from engaging in premature verification fishing expeditions intended to manufacture tolling before claims even arrive.

Practical Implications

Insurance carriers defending no-fault summary judgment motions must modify their submission practices to include actual IME and EUO scheduling letters whenever asserting tolling based on scheduled examinations. Bill delay letters alone no longer suffice. Carriers should maintain organized claim files ensuring that examination scheduling correspondence is readily accessible for litigation. When preparing summary judgment opposition papers, defense counsel must specifically request IME and EUO scheduling letters from clients rather than relying on generic bill delay documentation.

The decision creates heightened risk for carriers whose record-keeping practices do not preserve examination scheduling correspondence. Carriers who scheduled examinations but cannot locate the scheduling letters years later when litigation commences may lose tolling defenses despite having actually sent proper notices. This underscores the importance of comprehensive document retention policies specifically addressing examination scheduling correspondence.

Plaintiffs’ counsel should carefully scrutinize carriers’ summary judgment opposition papers for the presence or absence of actual examination scheduling letters. When carriers submit only bill delay letters referencing pending examinations without the underlying scheduling correspondence, plaintiffs should argue that PR Medical requires dismissal of tolling defenses. Motion papers should specifically cite the decision’s requirement that carriers submit scheduling letters, not mere assertions that scheduling occurred.

Discovery practice should address this issue early. Plaintiffs’ initial document demands should specifically request all IME scheduling letters, EUO scheduling letters, and related correspondence. When carriers fail to produce such documents, plaintiffs gain arguments that no scheduling actually occurred or that carriers cannot establish proper tolling compliance. Depositions of carriers’ claims handlers should explore whether scheduling letters were sent, when they were sent, and whether the carrier retained copies.

The decision also provides tactical guidance for carriers’ claim handling procedures. Claim files should specifically flag when IME or EUO scheduling occurs, preserve copies of all scheduling correspondence, and document the relationship between scheduling dates and the 30-day payment deadline. Supervisory review should ensure that examination scheduling occurs timely and that scheduling letters comply with all regulatory requirements, creating defensible records for potential litigation.

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