Non responded to verification fatal to plaintiff’s case

Last reviewed: September 2026.

Historical note: City Care concerns responses that expressly left requests unanswered, not a finding that every objection is invalid. For later denial timing and the response-or-justification provisions, see Chapa in 2026 and 11 NYCRR 65-3.5(o).

The providers’ own submissions supplied the decisive evidence. In City Care Acupuncture v Allstate, decided December 19, 2017, the Appellate Term affirmed dismissal as premature because the attached responses expressly said some requested verification was not being provided. The opinion does not identify every item requested or establish that every possible objection fails.

The actual parties and motion

City Care Acupuncture and Jamaica Wellness Medical sued as assignees of the same patient. The providers sought summary judgment; Allstate cross-moved to dismiss. The Civil Court granted the insurer’s cross-motion, and the providers appealed that part of the order.

Their motion papers included counsel’s affirmations and purported verification responses. Those responses expressly left some demands unanswered. The Appellate Term treated that record as showing that the insurer had not received all requested verification, so the action was premature.

The short opinion does not say the missing items were treatment notes, attendance records or billing documentation. It also does not describe a finding of dishonesty, a medical-necessity ruling or a fee-schedule calculation. Earlier explanatory copy supplied details and motives that the published decision did not establish; those assumptions should not accompany the case citation.

Why a response was not the same as completion

The issue was not whether the provider had sent any correspondence at all. A response can acknowledge a demand and still leave the requested information outstanding. Here, the responses themselves said that some verification was not being supplied.

That differs from a mailing dispute in which a provider says it sent the requested materials and the insurer denies receiving them. In the latter situation, the content and foundation of the mailing evidence may create a factual question. In City Care, the court relied on the providers’ expressed position about what they were not providing.

The decision cited Central Suffolk Hospital v New York Central Mutual, where a provider admitted receiving an initial verification request but did not state what response it made. Both decisions require attention to the actual response record. Neither gives a reader permission to assume that an insurer’s demand was properly made merely because it appears in a file.

Jason’s original December 2017 analysis

The following passage preserves Jason’s contemporary interpretation. Its opening inference about objections is his analysis; the published opinion does not reproduce the objections or decide their individual grounds.

This is interesting because we are left to reason that certain verification was objected to and certain verification was provided. The Court held that the failure to provide the requested verification (or to indicate where the verification could be obtained) renders the action premature. This Court has often stated that the failure to fully comply with verification renders the matter premature.

The opinion affirms dismissal as premature. It does not expressly label the disposition “without prejudice,” so that additional phrase is not attributed to this court here. Nor does the headline mean that the providers lost every possible substantive entitlement to benefits under every later factual scenario.

The regulation contains conditions, not an absolute slogan

11 NYCRR 65-3.8(a) ties the payment period to receipt of proof of claim, including relevant verification. The 120-day provisions in sections 65-3.5(o) and 65-3.8(b)(3) address a more specific situation: outstanding additional verification under the applicant’s possession or control, the alternative of written reasonable justification, and a required warning about possible denial.

Prescribed NF forms, IMEs and EUOs are expressly excluded from those particular provisions. The text also distinguishes applicability by treatment or service date for medical claims and accident date for lost earnings and expenses. A post’s publication year does not establish which provision governs the underlying claim.

City Care does not analyze those 120-day elements. It should therefore not be used as a substitute for proving them when an insurer relies on that defense. Likewise, an objection letter should be evaluated on its actual content; calling it an objection does not establish that it supplies reasonable justification.

Compare three different records

Solution Bridge’s 2018 decision involved a provider affidavit that raised a presumption of mailing and receipt, defeating the insurer’s summary-judgment motion. That result differs from an express statement that requested verification is not being supplied.

Progressive/Elite in 2018 concerned legal error in master-arbitration review of reasonable justification. It was not an across-the-board approval of incomplete responses.

Chapa in 2026 rejected an added mandatory 150-day denial deadline. The insurer there had issued denials. It did not hold that unanswered claims automatically disappear or that every verification defense succeeds without a denial.

A prematurity ruling is not a valuation of treatment

The order under review was entered in May 2015; the appellate decision followed in December 2017. The decision does not supply the underlying treatment dates or reproduce the verification correspondence. Those omissions matter when someone tries to apply a later regulatory mechanism solely from the date of the published case.

A prematurity defense asks whether the payment obligation being sued upon had reached the point at which suit could proceed. It is distinct from a defense that treatment was unnecessary, that a charge exceeded a fee schedule, or that an examination was missed. City Care did not decide those separate issues.

The response record also should not be reduced to a count of pages sent. A substantial packet can leave a specifically requested item unaddressed; a short written explanation may present a different question about reasonable justification. The regulation and the evidence determine the effect, not the physical size of the response.

Here, the court described express statements that some requested responses were not being provided. The opinion did not identify an accepted justification overcoming that problem. That is the limited reason the appeal failed, and the distinction that makes this historical decision worth reading beside cases involving contested mailing.

Reading a partial-response file

Match the response to the individual request and bill. Identify what was supplied, what remained outstanding, and whether the response explained an inability to comply. Then distinguish a dispute over those facts from a dispute over the legal effect of elapsed time.

For example, a cover letter enclosing records presents a different evidentiary question from a letter expressly declining to provide them. Neither description resolves a real claim by itself; the distinction explains why the City Care opinion focuses on the providers’ own submissions rather than speculation about their motives.

Connect to the Encyclopedia

Start with the verification requirements hub: Chapa, response evidence and denial timing. For the related historical decisions:

• Solution Bridge: claimed mailing created a factual dispute
• Compas/Praetorian: a response affidavit affected only one cause of action
• Allstate/Westchester: compliance found in arbitration
• Colonia: an investigation notice did not establish a verification request

For review of a particular no-fault dispute, request a Free Case Review.