Verification Requests

Additional verification is information the insurer requests to establish proof of claim beyond the prescribed forms. The insurer must forward the prescribed verification forms within 10 business days after receiving the application, and must request any additional verification within 15 business days of receiving the completed forms (11 NYCRR 65-3.5(a), (b)). A claim is not overdue until 30 calendar days after the insurer receives proof of claim, which includes the verification it requested (11 NYCRR 65-3.8(a)(1)), so a proper request delays the pay-or-deny deadline. Insurers may not demand verification without good reasons (11 NYCRR 65-3.2(c)), and an insurer's missed time frame does not excuse you from complying (11 NYCRR 65-3.5(p)).

Fifteen business days from receipt of the completed prescribed verification forms (11 NYCRR 65-3.5(b)). The prescribed forms themselves must be sent within 10 business days after the application (11 NYCRR 65-3.5(a)). If the verification is not supplied within 30 calendar days after the request, the insurer must follow up within 10 calendar days (11 NYCRR 65-3.6(b)). A late request is not ignored: each deviation from these rules reduces the insurer's 30 calendar days to pay or deny (11 NYCRR 65-3.8(l); Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294 (2007)), and the applicant must still comply with the request (11 NYCRR 65-3.5(p)).

The regulation does not list categories; it entitles the insurer to receive all items necessary to verify the claim directly from the parties from whom verification is requested (11 NYCRR 65-3.5(c)). In practice requests cover medical records and reports, wage verification from the employer (NF-6) or self-employment income proof (NF-7), an authorization for medical records, and the original assignment (11 NYCRR 65-3.4(c); 11 NYCRR 65-3.11(c)). An examination under oath requires specific objective justification, and a medical examination must be scheduled within 30 calendar days (11 NYCRR 65-3.5(d), (e)). Insurers may not demand verification without good reasons (11 NYCRR 65-3.2(c)).

You must supply, within 120 calendar days from the date of the initial request, all requested verification under your control or possession, or written proof providing reasonable justification for not complying (11 NYCRR 65-3.5(o)); the request must warn you of that deadline. After 120 days the insurer may deny the claim; it is not deemed denied automatically (11 NYCRR 65-3.8(b)(3)). The rule does not apply to prescribed NF forms, medical examination requests or examination under oath requests. Law changed April 1, 2013: 11 NYCRR 65-3.5(o) applies to treatment rendered on or after that date; earlier claims follow the prior rules.