Key Takeaway
Court clarifies that insurers can deny claims after second EUO no-show, with implications for providers who miss multiple examination appointments in complex cases.
When a healthcare provider repeatedly fails to appear for Examinations Under Oath (EUOs) in New York no-fault insurance cases, insurers gain significant leverage to deny claims. A recent appellate decision provides crucial guidance on when the clock starts ticking for insurance companies to make their coverage decisions, particularly in cases involving multiple no-shows.
The timing of EUO compliance has become increasingly important as insurers use these examinations as a primary tool to investigate potentially fraudulent claims. Understanding when a “failure to comply” becomes legally operative can mean the difference between payment and denial for healthcare providers seeking reimbursement under New York’s no-fault system.
This case highlights the complex interplay between procedural requirements and substantive coverage decisions, especially when EUO objections may prove futile and providers face multiple examination requests.
Jason Tenenbaum’s Analysis:
Quality Health Supply Corp. v Nationwide Ins., 2020 NY Slip Op 51226(U)(App. Term 2d Dept. 2020)
“Where, as here, no other verification request is outstanding (see Alev Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co., 38 Misc 3d 143, 2013 NY Slip Op 50258 ), the 30-day period for an insurer to pay or deny a claim (see 11 NYCRR 65-3.8 ) based upon a failure to appear for an EUO begins to run on the date of the second EUO nonappearance, when an insurer is permitted to conclude that there [*2]was a failure to comply with a condition precedent to coverage”.
This one is interesting because there were three (3) no shows. Assuming the second EUO was a reschedule, we are left to assume the third EUO would have been the “second” no-show. It would appear the movant in this weird situation would have to proffer evidence that the second EUO was somehow excused. Very interestging.
Key Takeaway
The court established that insurers can begin their 30-day decision period after the second EUO no-show, not the first. This creates strategic implications for providers facing multiple examination requests, as they must be prepared to explain why any missed appointment was excused, particularly when dealing with cases involving repeated non-appearances.
