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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)
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“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 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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Legal Context
Why This Matters for Your Case
New York's no-fault insurance system, established under Insurance Law Article 51, is one of the most complex insurance frameworks in the country. Every motorist must carry Personal Injury Protection coverage that pays medical expenses and lost wages regardless of fault, up to $50,000 per person.
But insurers routinely deny valid claims using peer reviews, EUO scheduling tactics, fee schedule reductions, and coverage defenses. The Law Office of Jason Tenenbaum has handled over 100,000 no-fault cases since 2002 — from initial claim submissions through arbitration before the American Arbitration Association, trials in Civil Court and Supreme Court, and appeals to the Appellate Term and Appellate Division. Jason Tenenbaum is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
His 2,353+ published legal articles on no-fault practice are cited by attorneys throughout New York. Whether you are dealing with a medical necessity denial, an EUO no-show defense, a fee schedule dispute, or a coverage question, this article provides the kind of detailed case-law analysis that helps practitioners and claimants understand exactly where the law stands.
About This Topic
New York No-Fault Insurance Law
New York's no-fault insurance system requires every driver to carry Personal Injury Protection (PIP) coverage that pays medical expenses and lost wages regardless of who caused the accident. But insurers routinely deny, delay, and underpay valid claims — using peer reviews, IME no-shows, and fee schedule defenses to avoid paying providers and injured claimants. Attorney Jason Tenenbaum has litigated thousands of no-fault arbitrations and court cases since 2002.
271 published articles in No-Fault
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
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