Reasonable excuse?

New York’s no-fault insurance system requires healthcare providers to submit claims within strict timeframes and to the correct insurance company. When providers send their NF-3 forms to the wrong insurer, they must demonstrate a reasonable excuse to avoid dismissal of their claims. A recent appellate decision illustrates just how difficult it can be to establish such justification when the error appears to be purely clerical.

The case highlights the importance of careful attention to procedural requirements in no-fault claims. While providers may sometimes receive relief for late submissions under certain circumstances, as discussed in our analysis of due consideration requirements, courts take a strict approach when evaluating whether mistakes justify non-compliance with basic filing requirements.

Jason Tenenbaum’s Analysis:

Karina K. Acupuncture, P.C. v Hertz Claim Mgt. Corp., 2018 NY Slip Op 51762(U)(App. Term 2d Dept. 2018)

“Plaintiff failed to demonstrate a reasonable justification for initially sending the NF-3 forms to GEICO rather than to defendant, as plaintiff’s NF-3 forms indicate that plaintiff was aware that the claims were to be sent to defendant. Since plaintiff failed to demonstrate the existence of a triable issue of fact, the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services rendered between July 6, 2007 and November 28, 2007 should have been granted.”

Clerical error will not suffice on a 45-day claim.

Key Takeaway

Healthcare providers cannot rely on simple clerical mistakes as reasonable justification for sending no-fault claims to the wrong insurance company. When the provider’s own forms demonstrate knowledge of the correct insurer, courts will not accept administrative errors as sufficient excuse for non-compliance with timely notice requirements under New York’s no-fault law.