Key Takeaway
Court rules medical provider failed to justify submitting no-fault claim to wrong insurer, despite claim form allegedly bearing correct carrier's information.
Medical Provider’s Late Claim Submission Rejected Due to Insufficient Justification
In New York’s no-fault insurance system, medical providers must submit claims to the correct insurance carrier within specified timeframes. When providers submit claims late or to the wrong insurer, they must demonstrate reasonable justification for the delay. A recent Appellate Term decision illustrates how courts scrutinize these explanations, particularly when the evidence suggests the provider had the correct information from the beginning.
The case involves a medical imaging provider that initially submitted a claim form to the wrong insurance company, then waited approximately one year before discovering the error and resubmitting to the correct carrier. The provider’s attempt to excuse this delay raises important questions about documentation and reasonable justification standards in no-fault practice.
Jason Tenenbaum’s Analysis:
New Millennium Med. Imaging, P.C. v 21st Century Ins. Co., 2022 NY Slip Op 50605(U)(App. Term 2d Dept. 2022)
“In opposition to defendant’s motion, plaintiff demonstrated that it had initially sent the claim form at issue to a different insurance company, and that, after plaintiff learned, approximately one year later, that [*2]the information it had regarding the insurance company covering the accident was incorrect, it sent the claim form to defendant. However, plaintiff did not establish a reasonable justification for initially submitting the claim form to the wrong insurance company, given that the claim form which plaintiff alleged it submitted to the wrong insurance company bore defendant’s name and address. As a result, plaintiff did not establish that it had provided defendant with a reasonable justification for its untimely submission of the claim form to defendant.”
I suspect the initial claim form had the incorrect insurance carrier, however, that claim form was not included in the record.
Key Takeaway
Courts require concrete evidence when providers claim reasonable justification for late no-fault submissions. Here, the provider’s explanation was undermined by its own allegation that the claim form contained the correct insurer’s information, making the initial misdirection unreasonable and unjustifiable under the circumstances.
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Frequently Asked Questions
What is New York's no-fault insurance system?
New York's no-fault insurance system requires all drivers to carry Personal Injury Protection (PIP) coverage. This pays for medical expenses and lost wages regardless of who caused the accident, up to policy limits. However, you can only sue for additional damages if you meet the 'serious injury' threshold.
