No-show based upheld despite objection – with a caveat

The effectiveness of objection letters in blocking insurance company EUO requests represents an unsettled area of New York no-fault law. Healthcare providers frequently attempt to object to EUO requests on various grounds, including claims that the examinations are duplicative, unnecessary, or overbroad. However, for such objections to have legal effect, providers must not only articulate valid grounds but also prove that their objection letters were properly mailed to the insurance company.

This case explores the intersection of two critical issues: whether unmailed objection letters can invalidate otherwise proper EUO requests, and whether properly mailed objections would have legal effect in preventing EUO-based disclaimers. The Appellate Term’s analysis provides important guidance about burden allocation and the procedural requirements for asserting objections to examination demands.

Understanding these principles is essential for providers who wish to resist EUO demands and for insurers seeking to enforce compliance with examination requests despite provider objections.

Case Background

First Class Med., P.C. v State Farm Mut. Auto. Ins. Co., 2017 NY Slip Op 50593(U)(App. Term 2d Dept. 2017)

(1) “At the outset we note that plaintiff failed to establish that it had mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 ) the objection letters that it attached to its opposition papers (see generally Crescent Radiology, PLLC v American Tr. Ins. Co., 31 Misc 3d 134, 2011 NY Slip Op 50622 2011] ).”

(2) “In any event, the no-fault regulations provide that an insurer may request that a provider submit to an EUO as may reasonably be required (see 11 NYCRR 65-1.1 ) and, here, defendant demonstrated that the requests for the EUOs at issue pertain to claims which it had received after the January 11, 2013 EUO had been conducted.”

Clearly, we have a situation where the EUO of the EIP occurred and then the facility was then brought in for an EUO. Objection letters were generated but not mailed. Would it have mattered if the letters were mailed? I see the words “in any event” and that could mean even if it was mailed, it would not be sufficient. I am unsure, however, if that is the case.

There has been a dearth of cases on this issue viz. can an EUO be validly blocked when an objection letter as to the EUO is mailed to the carrier. Again, we are waiting for the case where the objections letters are mailed and the Court reaches this precise issue. Stay tuned.

Legal Significance

The First Class Med decision establishes that providers bear the burden of proving proper mailing of objection letters when they seek to invalidate EUO requests. This burden allocation mirrors the requirements imposed on insurance companies when proving mailing of denials and other notices. Courts apply symmetrical evidentiary standards, requiring both sides to demonstrate compliance with proper mailing procedures when asserting that particular notices were sent and received.

The decision’s more intriguing aspect lies in the court’s alternative holding. The phrase “in any event” suggests that even if the objection letters had been properly mailed, they might not have invalidated the EUO requests. The court noted that the regulations permit insurers to request provider EUOs “as may reasonably be required,” and found that requesting a facility EUO after an injured person’s EUO was reasonable under the circumstances.

This alternative analysis raises important questions about the legal effect of objection letters more generally. If insurance companies can proceed with EUOs despite timely objections, the practical value of sending objection letters becomes questionable. However, the court’s analysis may be specific to the facts presented, where the insurer sought examination about new claims submitted after a prior EUO had been conducted.

Practical Implications for Providers and Insurers

Healthcare providers contemplating objections to EUO requests must take two critical steps. First, they must ensure proper mailing of any objection letters and maintain evidence of mailing through affidavits establishing standard office procedures. Simply generating objection letters without mailing them provides no protection whatsoever against EUO-based disclaimers.

Second, providers should recognize that even properly mailed objections may not prevent insurers from proceeding with EUOs when the circumstances demonstrate reasonable necessity. The regulatory framework permits insurers considerable discretion in determining when examinations are “reasonably required.” Objections based on claims of duplication or unnecessary examination face an uphill battle given this deferential standard.

For insurance companies, this decision reinforces that providers cannot defeat EUO-based disclaimers by simply attaching unmailed objection letters to opposition papers. Insurers should investigate whether objection letters were actually sent and challenge providers to establish proper mailing. Additionally, insurers can argue that even properly mailed objections do not invalidate examination requests when the EUOs address new claims, different time periods, or circumstances not covered by prior examinations.

The Unresolved Question

As Jason Tenenbaum notes in his analysis, the critical question remains unresolved: would properly mailed objection letters block otherwise valid EUO requests? The court’s use of “in any event” language suggests that mailing alone might not be sufficient, but the absence of actually mailed letters prevented the court from definitively addressing this issue. Until a case arises where objection letters were properly mailed and the court must squarely address their legal effect, practitioners cannot rely on objections as a definitive shield against EUO-based disclaimers.

Related Articles

• Understanding EUO Requirements in New York No-Fault Insurance Cases
• How to Challenge EUO No-Show Denials: When Improper Notice Can Reverse Insurance Denials in New York
• Personal Knowledge Requirements for EUO Non-Appearances: NY Legal Standards
• EUO No-Show Consequences: What Happens When You Skip Your Examination Under Oath in New York
• New York No-Fault Insurance Law