Key Takeaway
Court ruling on hearsay evidence in no-fault insurance fraud defenses and fee schedule denial requirements. Analysis of Box #18 denials and coverage disputes.
Acupuncture Healthcare Plaza I, P.C. v 21st Century Advantage Ins. Co.,2017 NY Slip Op 50945(U)(App. Term 2d Dept. 2017)
Fee Schedule: Box #18
(1) “Contrary to plaintiff’s contention, the denial of claim forms were sufficient to advise plaintiff that defendant was partially denying plaintiff’s claims on the ground that the amount plaintiff sought to recover was not in accordance with the workers’ compensation fee schedule. Indeed, a checked box on the forms indicated that benefits were denied because the fees were not in accordance with the fee schedule (see Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 47 Misc 3d 149, 2015 NY Slip Op 50778 ; Arco Med. NY, P.C. v Lancer Ins. Co., 37 Misc 3d 136, 2012 NY Slip Op 52178 ).”
Lack of coverage
(2) “To the extent defendant seeks summary judgment dismissing these claims on the ground of lack of coverage, a defense which is not subject to preclusion (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 ), defendant’s evidence was insufficient to establish, as a matter of law, that the assignor’s alleged injuries did not arise from an insured incident so as to warrant the dismissal of the complaint (see Central Gen. Hosp., 90 NY2d at 199; Infinity Health Prods., Ltd. v American Tr. Ins. Co., 30 Misc 3d 137, 2011 NY Slip Op 50195 ).”
(Infinity involved an SIU affidavit relying in large part on an inadmissible police report)
Related Articles
- Fee schedule defense requirements and competent evidence standards
- Competent evidence standards for fee schedule defenses
- Understanding medical billing and down-coding in no-fault claims
- How hearsay evidence affects civil court no-fault insurance decisions
- New York No-Fault Insurance Law
Legal Update (February 2026): The fee schedule provisions and reimbursement rates discussed in this 2017 post may have been substantially modified through regulatory amendments and updated fee schedules implemented since publication. Additionally, procedural requirements for fee schedule denials and coverage defenses may have evolved through subsequent regulatory changes and case law developments. Practitioners should verify current fee schedule provisions and denial requirements under the most recent regulations.
