New York No-Fault Regulations 11 NYCRR Subpart 65-3: Claims for Personal Injury Protection Benefits

11 NYCRR 65-3.8: Payment or denial of claim (30-day rule)

Text of 11 NYCRR 65-3.8 (Insurance Regulation 68-C) as published by the New York State Department of Financial Services, checked against the Department's list of amendments through October 4, 2026.

This is an unofficial copy. The official text is in the New York Codes, Rules and Regulations. Decisions apply the version in force at the time of the claim, which may differ from the current text.

Decisions citing this section · Plain-text version (Markdown)

(a) (1) No-fault benefits are overdue if not paid within 30 calendar days after the insurer receives proof of claim, which shall include verification of all of the relevant information requested pursuant to section 65-3.5 of this Subpart. In the case of an examination under oath or a medical examination, the verification is deemed to have been received by the insurer on the day the examination was performed.

(2) An insurer shall defer payment of OBEL benefits for claims submitted by or on behalf of the eligible injured person until an OBEL option has been elected in accordance with section 65-3.7 of this Subpart. An insurer shall pay or deny such claims under OBEL coverage within 30 calendar days of the date that an election has been made.

(b) (1) An insurer may not interrupt the payment of benefits for any element of basic or extended economic loss pending the administering of a medical examination, unless the applicant or the applicant’s attorney is responsible for the delay or inability to schedule the examination, in which case any denial of payment shall be made only in accordance with policy provisions on a prescribed denial of claim form (NYS form NF-10).

(2) Notwithstanding paragraph (1) of this subdivision, if the insurer has information which clearly demonstrates that the applicant is no longer disabled, the insurer may discontinue the payment of benefits by forwarding to the applicant a prescribed denial of claim form.

(3) Except as provided in subdivision (e) of this section, an insurer shall not issue a denial of claim form (NYS form NF-10) prior to its receipt of verification of all of the relevant information requested pursuant to sections 65-3.5 and 65-3.6 of this Subpart (e.g., medical reports, wage verification, etc.). However, an insurer may issue a denial if, more than 120 calendar days after the initial request for verification, the applicant has not submitted all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply, provided that the verification request so advised the applicant as required in section 65-3.5(o) of this Subpart. This subdivision shall not apply to a prescribed form (NF-form) as set forth in Appendix 13 of this Title, medical examination request, or examination under oath request. This paragraph shall apply, with respect to claims for medical services, to any treatment or service rendered on or after April 1, 2013, and with respect to claims for lost earnings and reasonable and necessary expenses, to any accident occurring on or after April 1, 2013.

(4) If the specific reason for a denial of a no-fault claim, or any element thereof, is a medical examination or peer review report requested by the insurer, the insurer shall release a copy of that report to the applicant for benefits, the applicant’s attorney, or the applicant’s treating physician, upon the written request of any of these parties.

(c) Within 30 calendar days after proof of claim is received, the insurer shall either pay or deny the claim in whole or in part.

(1) If the insurer denies a claim in whole or in part involving elements of basic economic loss or extended economic loss, the insurer shall notify the applicant or the authorized representative on the prescribed denial of claim form, in duplicate, and shall furnish, if requested by the applicant, one copy of all prescribed claim forms submitted by or on behalf of the applicant thereto. However, where a denial involves a portion of a health provider’s bill, the insurer may make such a denial on a form or letter approved by the department which is issued in duplicate. No form or letter shall be approved unless it contains substantially the same information as the prescribed form which is relevant to the claim denied.

(2) Notwithstanding paragraph (1) of this subdivision, where there is a denial in part of a medical bill as a result of charges not conforming to section 5108 of the Insurance Law, an insurer may effect compliance with paragraph (1) of this subdivision for those overcharges of $50 or less by telephone agreement with the provider or provider’s representative, with proper documentation of such agreement in the claim file. The provider must have been entitled to direct payment pursuant to section 65-3.11 of this Subpart.

(d) Where an insurer denies part of a claim, it shall pay benefits for the undisputed elements of the claim. Such payments shall be made without prejudice to either party.

(e) If an insurer has determined that benefits are not payable for any of the following reasons:

(1) no coverage on the date of accident;

(2) circumstances of the accident not covered by no-fault; or

(3) statutory exclusions pursuant to section 5103(b) of the Insurance Law; it shall notify the applicant within 10 business days after such determination on a prescribed denial of claim form, specifying the reasons for the denial. Failure by an insurer to notify the applicant of its denial of the claim within the 10-business-day period after its determination shall not preclude the insurer from asserting a defense to the claim which is based upon the reasons for such denial.

(f) An insurer shall be entitled to receive proper proof of claim and a failure to observe any of the time frames specified in this section shall not prevent an insurer from requiring proper proof of claim.

(g) (1) Proof of the fact and amount of loss sustained pursuant to Insurance Law section 5106(a) shall not be deemed supplied by an applicant to an insurer and no payment shall be due for such claimed medical services under any circumstances:

(i) when the claimed medical services were not provided to an injured party; or

(ii) for those claimed medical service fees that exceed the charges permissible pursuant to Insurance Law section 5108(a) and (b) and the regulations promulgated thereunder for services rendered by medical providers.

(2) This subdivision shall apply to medical services rendered on or after April 1, 2013.

(h) With respect to a denial of claim (NYS form NF-10), an insurer’s non-substantive technical or immaterial defect or omission shall not affect the validity of a denial of claim. This subdivision shall apply to medical services rendered, and to lost earnings and other reasonable and necessary expenses incurred, on or after April 1, 2013.

(i) Notwithstanding subdivision (e) of this section, if an insurer has reason to believe that the applicant was operating a motor vehicle while intoxicated or impaired by the use of a drug, and such intoxication or impairment was a contributing cause of the automobile accident, the insurer shall be entitled to all available information relating to the applicant’s condition at the time of the accident. Proof of a claim shall not be complete until the information which has been requested, pursuant to section 65-3.5(a) or (b) of this Subpart, has been furnished to the insurer by the applicant or the authorized representative.

(j) Where the insurer has determined that a self-employed applicant’s disability arose from the claimed accident, the insurer shall be deemed to have proof of claim for loss of earnings or substitute services, subject to receipt of medical proof of disability for the period claimed, when it has received a completed prescribed verification of self-employment income form (NYS form NF-7) and the proof requested thereon. The insurer shall determine therefrom the amount of loss of earnings benefits, if any, due the applicant. Notwithstanding the above, if an insurer requires verification in addition to the proof supplied, it may request such additional verification pursuant to section 65-3.5(b) of this Subpart.

(k) A death benefit claim will be deemed to have been proven when the insurer receives a copy of the decedent’s death certificate and proof that the personal representative of the decedent’s estate was duly appointed in this State or any other jurisdiction.

(l) For the purposes of counting the 30 calendar days after proof of claim, wherein the claim becomes overdue pursuant to section 5106 of the Insurance Law, with the exception of section 65-3.6 of this Subpart, any deviation from the rules set out in this section shall reduce the 30 calendar days allowed.

Example: Where an insurer sends an application for motor vehicle no-fault benefits 15 business days after notice is received at the address of the insurer’s proper claim processing office instead of five business days, the 30 calendar days permitted by subdivision (a) of this section are reduced to 20 calendar days.

Historical note

Sec. filed Aug. 2, 2001; amds. filed: Jan. 17, 2003; Jan. 30, 2013 eff. April 1, 2013. Amended (b)(3), relettered (g)-(j) to (i)-(l), added new (g), (h).

Decisions citing this section (597)

Every decision in our case-law database that cites 11 NYCRR 65-3.8, grouped by the subdivision cited. Within each group, decisions that turn on the provision come first, then those that rely on it, then passing citations; within each of these the highest court comes first. The lists are compiled automatically, and the one-sentence descriptions were written by a language model from the text of each decision: read the decision before relying on one.

Effective April 1, 2013, subdivisions (g)-(j) were relettered (i)-(l) and new subdivisions (g) and (h) were added. A decision dated before April 1, 2013 that cites (g), (h), (i) or (j) refers to what is now (i), (j), (k) or (l). A later decision on an older claim may still use the earlier lettering. Decisions dated before the change are listed under the current letter.

(a) 282 (b) 85 (c) 198 (d) 1 (e) 7 (f) 2 (g) 31 (h) 4 (i) 9 (l) 44 no subdivision 53

Subdivision (a) (282 decisions)

Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2015 NY Slip Op 04787) Court of AppealsRelies on (a) (1) in holding that a provider establishes entitlement to overdue benefits by proving submission of a completed claim form and neither payment nor denial within 30 days, with admissible proof of mailing required for summary judgment.
Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 09484) Appellate Division, Second DepartmentApplies (a) (1) to dismiss a hospital provider's claim where it admitted receiving the insurer's initial verification request but failed to state whether it responded, leaving the insurer without an obligation to pay or deny.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430) Appellate Division, Second DepartmentHolds under (a) (1) that a provider establishes prima facie entitlement to summary judgment through proof that billing forms were mailed and received and claims were not timely paid or denied, without proving the merits of their contents as business records.
New York Univ. Hosp. Rusk Inst. v Government Empls. Ins. Co. (2007 NY Slip Op 03671) Appellate Division, Second DepartmentApplies (a) (1) in finding that timely medical-verification requests and a timely denial based on a peer review attributing treatment to a preexisting condition raised triable issues defeating the provider's summary judgment motion.
Matter of MVAIC v Interboro Med. Care & Diagnostic PC (2010 NY Slip Op 04522) Appellate Division, First DepartmentRejects the arbitrator's use of (a) (1)'s 30-day deadline to bar the insurer's lack-of-coverage defense, vacating the award and remanding for a determination of coverage.
Nationwide Affinity Ins. Co. of Am. v George (2020 NY Slip Op 02801) Appellate Division, Second DepartmentApplies (a) (1) in finding denials timely where office-practice affidavits established mailing within 30 days of the second scheduled EUO and the providers failed to raise a factual issue about the insurer's mailing procedures.
New York & Presbyt. Hosp. v Countrywide Ins. Co. (2007 NY Slip Op 07675) Appellate Division, Second DepartmentApplies (a) (1) to hold that requested verification tolls the payment-or-denial period until all relevant information arrives, denying summary judgment on one claim because admissible insurer evidence raised issues about billing dates and pending verification.
Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc. (2011 NY Slip Op 00217) Appellate Division, Second DepartmentApplies (a) (1) to uphold the provider's summary judgment award where mailed and received billing documents established overdue payment and the insurers failed to raise a triable issue concerning timely denial.

Show all 282 decisions

St. Vincent Med. Care, P.C. v Country Wide Ins. Co. (2011 NY Slip Op 00214) Appellate Division, Second DepartmentApplies (a) (1) to hold the action premature because incomplete compliance with verification requests prevented the 30-day payment-or-denial period from beginning, notwithstanding follow-up requests sent on the 30th day after the initial requests.
Westchester Med. Ctr. v Liberty Mut. Ins. Co. (2007 NY Slip Op 04483) Appellate Division, Second DepartmentApplies (a) (1) to grant the provider summary judgment where matching mailing documents and postal tracking established delivery of requested medical records, rebutting the insurer's outstanding-verification assertion, and payment was not made within 30 days of receipt.
Montefiore Med. Ctr. v Government Empls. Ins. Co. (2006 NY Slip Op 08953) Appellate Division, Second DepartmentHolds that an additional verification request following an N-F5 submission tolls the insurer's time to pay or deny under (a) (1) until all relevant requested information is received, without requiring a prescribed form.
Quality Health Supply Corp. v Nationwide Ins. (2023 NY Slip Op 02689) Appellate Division, Second DepartmentApplies (a) in finding the insurer's denial after the last scheduled EUO timely and proper, supporting dismissal where the assignor failed to appear and the insurer properly mailed and followed up on EUO requests.
Westchester Med. Ctr. v Allstate Ins. Co. (2008 NY Slip Op 06146) Appellate Division, Second DepartmentApplies (a) (1) to deny the provider summary judgment because the insurer raised a triable issue whether the provider complied with timely, properly sent verification requests for the assignor's toxicology information.
New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co. (2011 NY Slip Op 01628) Appellate Division, Second DepartmentApplies (a) (1) to grant summary judgment where billing forms, biller affidavits, and certified mail records established mailing, receipt, and overdue payment, and the insurer failed to raise a triable issue.
New York Univ. Hosp.-Tisch Inst. v Government Empls. Ins. Co. (2014 NY Slip Op 03812) Appellate Division, Second DepartmentApplies (a) (1) to hold that the insurer raised a factual issue about timely denial after verification tolling, defeating the providers' summary judgment motion.
Westchester Med. Ctr. v Lancer Ins. Co. (2012 NY Slip Op 02867) Appellate Division, Second DepartmentApplies (a) (1) to deny the provider summary judgment because the insurer timely requested additional verification and denied the claim within 30 days after receiving the requested information.
Matter of Advanced Orthopaedics, PLLC v Country-Wide Ins. Co. (2022 NY Slip Op 02406) Appellate Division, Second DepartmentHolds that an initial EUO request sent more than 30 days after claim receipt is a nullity under (a), and that excusing its lateness under the verification rules irrationally permits evasion of the payment deadline.
New York Univ. Hosp. Rusk Inst. v Illinois Natl. Ins. Co. (2006 NY Slip Op 05601) Appellate Division, Second DepartmentRelies on (a) (1) to treat the provider's failure to comply with verification demands as a potentially meritorious defense supporting vacatur of the insurers' default judgment.
Wyckoff Hgts. Med. Ctr. v Country-Wide Ins. Co. (2010 NY Slip Op 02552) Appellate Division, Second DepartmentApplies (a) (1) in finding that proof of mailing and receipt of the necessary billing forms and overdue payment established the provider's prima facie entitlement to summary judgment; the insurer raised no triable issue.
Matter of American Tr. Ins. Co. v Heyligers (2026 NY Slip Op 04363) Appellate Division, First DepartmentApplies (a) (1) to uphold the arbitrator's finding that verification tolling ended because requested information had been furnished, including information sought again in an unanswered request, making the master arbitrator's affirmance reasonable.
Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U)) Appellate Term, Second DepartmentApplies (a) (1) to find that the insurer failed to pay or deny within 30 days after receiving requested verification, supporting preclusion of its defenses.
ARCO Med. N.Y., P.C. v Lancer Ins. Co. (2011 NY Slip Op 52382(U)) Appellate Term, Second DepartmentApplies (a) to find a claim submitted after the provider's EUO nonappearances timely and properly denied within 30 days of receipt, leaving the EUO defense available and defeating the provider's summary judgment cross motion.
Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 24145) Appellate Term, Second DepartmentHolds that, for tolling under (a) (1), a mailed verification request is complete upon delivery to the Postal Service, so the operative issue is whether the insurer mailed the requests rather than whether the provider received them.
Neptune Med. Care, P.C. v Ameriprise Auto & Home Ins. (2015 NY Slip Op 51220(U)) Appellate Term, Second DepartmentHolds that a verification toll under (a) does not permit otherwise untimely verification requests, so EUO scheduling letters sent more than 30 days after receipt of the bills were nullities as to those bills.
D & R Med. Supply v American Tr. Ins. Co. (2011 NY Slip Op 51727(U)) Appellate Term, Second DepartmentHolds under (a) that the provider's responses failed to supply requested verification because they omitted the prescribing doctor's name and location, leaving the payment-or-denial period untriggered and requiring dismissal as premature.
Quality Health Supply Corp. v Nationwide Ins. (2020 NY Slip Op 51226(U)) Appellate Term, Second DepartmentHolds under (a) (1) that, when no other verification remains outstanding, the insurer's 30-day period to pay or deny for EUO nonappearance begins on the second nonappearance.
Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2024 NY Slip Op 24111) Appellate Term, Second DepartmentHolds under (a) (1) that an EUO request tolls payment or denial until the EUO occurs, without extending the deadline for new verification requests; the insurer therefore failed to establish timely denials supporting its summary judgment motion.
Mary Immaculate Hosp. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 52046(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the second claim as premature because the provider had not supplied requested assignment verification; rejects the contention that the follow-up request inadequately identified the missing information.
East Acupuncture, P.C. v Allstate Ins. Co. (2007 NY Slip Op 27109) Appellate Term, Second DepartmentApplies (a) (1) to hold that interest on unpaid claims accrues 30 days after submission despite an untimely denial, subject to the separate interest toll for delay in suing or seeking arbitration.
Island Life Chiropractic Pain Care, PLLC v 21st Century Ins. Co. (2021 NY Slip Op 21340) Appellate Term, Second DepartmentHolds under (a) (1) that the EUO toll ended at the second nonappearance for an existing claim, but later claims could still be denied within 30 days of receipt on the same ground despite the earlier claim's untimely denial.
S&M Supply Inc. v Peerless Ins. Co. (2004 NY Slip Op 51683(U)) Appellate Term, Second DepartmentApplies (a) to award partial summary judgment on a claim denied more than 30 days after submission, where complete proof of claim established overdue payment and the late denial precluded most defenses.
Alev Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50258(U)) Appellate Term, Second DepartmentHolds that IME nonappearance denials were timely under (a) because they issued within 30 days after receipt of requested written verification, although the last missed IME occurred more than 45 days before denial.
Chapa Prods. Corp. v MVAIC (2019 NY Slip Op 29341) Appellate Term, Second DepartmentApplies (a) (1)'s 30-day period after the 120-day verification period expires, holding that denials mailed 208 days after the initial requests failed to preserve the incomplete-verification defense.
Vista Surgical Supplies, Inc. v General Assur. Co. (2006 NY Slip Op 51034(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the provider's action as premature because timely verification and follow-up requests remained unanswered when suit began, so the insurer's time to pay or deny had not elapsed.
Pomona Med. Diagnostics, P.C. v Travelers Ins. Co. (2011 NY Slip Op 50447(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal as premature because unanswered verification requests left the payment-or-denial period untriggered; the provider's biller's mere denial of receipt did not rebut the presumption that the requests were mailed and received.
A.B. Med. Servs., PLLC v Country-Wide Ins. Co. (2009 NY Slip Op 51016(U)) Appellate Term, Second DepartmentApplies (a) to hold claims overdue and grant the providers summary judgment because the insurer's nonspecific affidavit failed to establish that requested verification remained outstanding and tolled its time to pay or deny.
Active Care Med. Supply Corp. v MVAIC (2019 NY Slip Op 52045(U)) Appellate Term, Second DepartmentApplies (a) (1) to find that the insurer neither denied the claims within 30 days of receipt nor timely extended that period by requesting verification.
Daily Med. Equip. Distrib. Ctr., Inc. v MVAIC (2016 NY Slip Op 51622(U)) Appellate Term, Second DepartmentApplies (a) (1) to find that the insurer neither denied the claims within 30 days of receipt nor timely extended that period by requesting verification, rejecting dismissal on the ground that the action was premature.
Compas Med., P.C. v Farm Family Cas. Ins. Co. (2013 NY Slip Op 50254(U)) Appellate Term, Second DepartmentApplies (a) (1) to find eight denials untimely and preclude the insurer's defense that the assignor failed to attend duly scheduled EUOs.
Morris Med., P.C. v Amex Assur. Co. (2012 NY Slip Op 52260(U)) Appellate Term, Second DepartmentApplies (a) (1) to find that the insurer failed to establish that its EUO condition-precedent defense escaped preclusion on five claims left unpaid and undenied beyond 30 days, with no EUO requested or pending during that period.
Ezra Supply, Inc. v Nationwide Affinity Ins. Co. of Am. (2022 NY Slip Op 22383) Appellate Term, Second DepartmentRelies on (a) (1) and quoted precedent to hold that, absent other outstanding verification, the 30-day period begins at the second EUO nonappearance, so later EUO opportunities do not preserve the toll.
Island Life Chiropractic, P.C. v Travelers Ins. Co. (2019 NY Slip Op 51273(U)) Appellate Term, Second DepartmentRelies on (a) to place the initial trial burden on the insurer to prove timely verification requests and nonreceipt, explaining that an order establishing timely mailing does not relieve the insurer of proving nonreceipt.
A.C. Med., P.C. v Ameriprise Ins. Co. (2016 NY Slip Op 51787(U)) Appellate Term, Second DepartmentApplies (a) (1) to find that the insurer failed to deny a claim timely after the provider's second EUO nonappearance, defeating the insurer's request for summary judgment on its nonappearance defense.
Compas Med., P.C. v Travelers Ins. Co. (2016 NY Slip Op 51441(U)) Appellate Term, Second DepartmentApplies (a) (1) to reject the provider's contention that a partial verification response required payment or denial, affirming dismissal because all demanded verification had not been provided.
Concourse Chiropractic, PLLC v Fiduciary Ins. Co. of Am. (2012 NY Slip Op 51058(U)) Appellate Term, Second DepartmentHolds that an untimely follow-up EUO request failed to toll the 30-day period under (a) (1), making the denial untimely and warranting denial of the insurer's summary judgment cross motion based on the assignor's EUO nonappearance.
Align for Health Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 51862(U)) Appellate Term, Second DepartmentApplies (a) to deny the insurer's cross motion because it failed to prove timely mailing of initial and follow-up verification requests and therefore failed to establish that the provider's action was premature.
SZ Med. P.C. v State-Wide Ins. Co. (2005 NY Slip Op 50103(U)) Appellate Term, Second DepartmentApplies (a) (1) to require proof that 30 days elapsed after receipt of the claims sued upon; undated submission evidence and acknowledgment letters identifying no particular claims failed to establish overdue payment.
Avicenna Med. Arts, PLLC v Unitrin Advantage Ins. Co. (2015 NY Slip Op 50382(U)) Appellate Term, Second DepartmentApplies (a) (1) to preclude the insurer's EUO nonappearance defense and affirm judgment on the first six causes of action because follow-up EUO requests were untimely and the claims were not denied within 30 days of receipt.
Triangle R, Inc. v Clarendon Ins. Co. (2010 NY Slip Op 52159(U)) Appellate Term, Second DepartmentApplies (a) to hold the action premature because the provider did not demonstrate that it supplied requested verification before suit; sending the assignor's copies to a wrong address did not invalidate requests directed to the provider.
Proscan Imaging, P.C. v Travelers Indem. Co. (2010 NY Slip Op 51176(U)) Appellate Term, Second DepartmentApplies (a) to hold the action premature because the provider did not demonstrate that it furnished requested verification before suing, so the 30-day payment-or-denial period had not begun.
Alur Med. Supply, Inc. v Eveready Ins. Co. (2009 NY Slip Op 51492(U)) Appellate Term, Second DepartmentApplies (a) to require dismissal as premature because the provider sued before responding to timely initial and follow-up verification requests, so the insurer's time to pay or deny had not elapsed.
Dilon Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 52266(U)) Appellate Term, Second DepartmentApplies (a) (1) to reject the insurer's claimed extension of the 30-day determination period because it supplied no evidence that its EUO requests were mailed, leaving its denial untimely.
Wave Med. Servs., P.C. v Hertz Vehs., LLC (2022 NY Slip Op 50908(U)) Appellate Term, Second DepartmentRelies on (a) (1) to treat claim receipt as part of the provider's prima facie case, explaining that proof of nonreceipt rebuts that case and, if accepted, completely defeats the action.
New Horizon Surgical Ctr., LLC v Travelers Ins. Co. (2019 NY Slip Op 51690(U)) Appellate Term, Second DepartmentHolds under (a) (1) that a partial response to verification requests does not require payment or denial, granting the insurer summary judgment because requested verification remained outstanding.
Compas Med., P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51228(U)) Appellate Term, Second DepartmentApplies (a) (1) to deny insurer summary judgment on one fee-schedule claim because the insurer failed to establish a timely denial and therefore failed to show that its defense was not precluded.
Daily Med. Equip. Distrib. Ctr., Inc. v Interboro Ins. Co. (2017 NY Slip Op 50958(U)) Appellate Term, Second DepartmentApplies (a) to hold the provider's action premature because requested verification remained outstanding when suit commenced, so the insurer's 30-day payment-or-denial period had not begun.
Excel Surgery Ctr., L.L.C. v Fiduciary Ins. Co. of Am. (2017 NY Slip Op 50408(U)) Appellate Term, Second DepartmentApplies (a) (1) to hold the action premature because the insurer had not received requested verification and the provider failed to show that it supplied all requested items in its possession, so the payment-or-denial period had not begun.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51667(U)) Appellate Term, Second DepartmentApplies (a) (1) to find the third claim was not denied within 30 days, with no demonstrated tolling, precluding the insurer's IME and EUO nonappearance defenses and entitling the provider to summary judgment on that claim.
Compas Med., P.C. v ELRAC, Inc. (2015 NY Slip Op 50675(U)) Appellate Term, Second DepartmentApplies (a) to hold that letters labeled verification or delay requests did not establish tolling of the 30-day deadline, leaving the insurer unable to obtain summary judgment on two claims.
Power Supply, Inc. v Praetorian Ins. Co. (2015 NY Slip Op 50218(U)) Appellate Term, Second DepartmentHolds under (a) that timely EUO requests kept the denial period tolled beyond earlier IME nonappearances, making denials issued within 30 days after the second EUO nonappearance timely even though the IME nonappearances occurred more than 30 days before denial.
Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 50347(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature because verification remained outstanding, rejecting the provider's contention that resubmission of an identical claim restarted the insurer's 30-day period to pay or deny.
Brooklyn Chiropractic & Sports Therapy, P.C. v A. Cent. Ins. Co. (2013 NY Slip Op 50904(U)) Appellate Term, Second DepartmentApplies (a) to dismiss two claims as premature because the insurer proved timely mailing of initial and follow-up verification requests and never received responses, so its time to pay or deny had not begun.
Ortho Prods. & Equipments, Inc. v Eveready Ins. Co. (2013 NY Slip Op 50856(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action because the provider's claim forms lacked substantially the same information as the requested NF-3 forms and the provider did not demonstrate full verification compliance before suit, leaving the 30-day period untriggered.
Triangle R, Inc. v Tri-State Consumer Ins. Co. (2013 NY Slip Op 50256(U)) Appellate Term, Second DepartmentApplies (a) to dismiss unanswered claims as premature because the payment or denial period had not begun, after the provider's mere denial of receipt failed to overcome the presumption that verification requests were properly mailed and received.
All Boro Psychological Servs., P.C. v Allstate Ins. Co. (2013 NY Slip Op 50069(U)) Appellate Term, Second DepartmentApplies (a) to award summary judgment dismissing the complaint to the nonappealing insurer after searching the record, because uncontroverted nonresponse to timely initial and follow-up verification requests left the 30-day payment or denial period untriggered.
Huntington Hosp. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52274(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature on unrebutted proof of timely verification requests and nonresponse, and rejects the provider's contention that the insurer had denied the particular bill.
Alev Med. Supply, Inc. v Eveready Ins. Co. (2012 NY Slip Op 52184(U)) Appellate Term, Second DepartmentHolds that under (a), the 30-day payment or denial period had not begun because timely initial and follow-up verification requests remained unanswered when suit commenced, requiring dismissal of the provider's action as premature.
Infinity Health Prods. Ltd. v Liberty Mut. Fire Ins. Co. (2012 NY Slip Op 50774(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature because the claims specialist's affidavit established timely verification requests and nonresponse, contrary to the trial court's finding, and the provider never alleged compliance, so the 30-day payment or denial period had not begun.
Radiology Today, P.C. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 52452(U)) Appellate Term, Second DepartmentHolds under (a) that unanswered requests for the assignor's MRI films prevented the 30-day payment-or-denial period from starting, making the provider's action premature and warranting summary judgment dismissing the complaint.
Eagle Surgical Supply, Inc. v Travelers Indem. Co. (2010 NY Slip Op 51775(U)) Appellate Term, Second DepartmentApplies (a) to affirm summary judgment dismissing the complaint because the insurer timely requested additional verification and the record unequivocally showed that the provider had not supplied all of it.
A.B. Med. Servs., PLLC v Country-Wide Ins. Co. (2008 NY Slip Op 52651(U)) Appellate Term, Second DepartmentApplies (a) to hold claims overdue and grant the providers summary judgment because the insurer's nonspecific affidavit failed to establish that requested verification remained outstanding and tolled its time to pay or deny.
Gotham Acupuncture, P.C. v Country Wide Ins. Co. (2008 NY Slip Op 51615(U)) Appellate Term, First DepartmentApplies (a) (1) in granting the provider summary judgment where the insurer failed to prove denial forms were mailed within 30 days, precluding its excessive-fee defense.
Dilon Med. Supply Corp. v State Farm Mut. Ins. Co. (2006 NY Slip Op 51344(U)) Appellate Term, Second DepartmentApplies (a) (1) to hold that letters announcing delayed payment pending investigation of the accident and the assignor's eligibility did not toll the 30-day period, leaving the denial untimely and most defenses precluded.
A.B. Med. Servs. PLLC v Allstate Ins. Co. (2005 NYSlipOp 51270(U)) Appellate Term, Second DepartmentApplies (a) (1)'s 30-day deadline in granting partial summary judgment because the insurer's adjuster affidavit established neither actual mailing of the denials nor office procedures ensuring proper addressing and mailing.
A.C. Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2021 NY Slip Op 50841(U)) Appellate Term, Second DepartmentApplies (a) (1) to dismiss the action as premature because timely initial and follow-up verification requests remained unanswered, so the insurer's 30-day period to pay or deny had not begun.
Lenox Hill Radiology & MIA, P.C. v Global Liberty Ins. Co. of N.Y. (2018 NY Slip Op 51810(U)) Appellate Term, Second DepartmentApplies (a) to hold the action premature because timely initial and follow-up verification requests remained unanswered when suit began, so the insurer's 30-day period to pay or deny had not started.
MT Servs. P.T., P.C. v Country-Wide Ins. Co. (2017 NY Slip Op 51851(U)) Appellate Term, Second DepartmentApplies (a) to hold that the 30-day payment-or-denial period had not begun because requested verification remained outstanding when suit commenced, affirming dismissal where the provider failed to show that it had supplied the material before suing.
Active Chiropractic, P.C. v Country-Wide Ins. Co. (2017 NY Slip Op 51850(U)) Appellate Term, Second DepartmentApplies (a) to hold that the 30-day payment-or-denial period had not begun for the appealed claim because verification remained outstanding and the provider failed to show that it had supplied the material before suit, affirming dismissal of that claim.
New Quality Med., P.C. v Allstate Ins. Co. (2016 NY Slip Op 50871(U)) Appellate Term, Second DepartmentApplies (a) to find that the insurer failed to raise a factual issue concerning timely denial, making its argument about a possible factual dispute over the provider's EUO nonappearance irrelevant and affirming summary judgment for the provider.
Alleviation Med. Servs., P.C. v Farmers New Century Ins. Co. (2016 NY Slip Op 50379(U)) Appellate Term, Second DepartmentApplies (a) (1) to establish the provider's prima facie case from claim submission and the insurer's admission that denial exceeded 30 days; absent proof of tolling, the IME nonappearance defense was precluded and the provider obtained summary judgment on that claim.
Parkview Med. Advanced, P.C. v Travelers Ins. Co. (2015 NY Slip Op 51873(U)) Appellate Term, Second DepartmentApplies (a) to hold eight claims premature because the insurer's unopposed proof established timely initial and follow-up verification requests and nonreceipt of the requested verification, so the 30-day payment or denial period never began.
New Way Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51627(U)) Appellate Term, Second DepartmentHolds under (a) that the claim is premature because requested verification remained outstanding when suit began, so the insurer's 30-day period to pay or deny had not begun to run.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51467(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal of the third cause of action as premature where the insurer proved timely initial and follow-up verification requests and nonreceipt of verification, and the provider raised no triable issue.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51408(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal of the second cause of action as premature where the insurer proved timely initial and follow-up verification requests and nonreceipt of verification, and the provider raised no triable issue.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51403(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal of the fifth cause of action as premature where the insurer proved timely initial and follow-up verification requests and nonreceipt of verification, and the provider raised no triable issue.
South Nassau Orthopedic Surgery & Sports Medicine, P.C. v Farm Family Cas. Ins. Co. (2015 NY Slip Op 51211(U)) Appellate Term, Second DepartmentApplies (a) (1) to find denials untimely because each bill had to be denied within 30 days after its receipt or completion of the assignor's EUO, whichever was later, and no other verification remained outstanding.
Parkview Med. & Surgical, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50491(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the first cause of action as premature because timely requested verification remained outstanding and the provider did not show it had supplied the verification before suit, so the 30-day payment or denial period had not begun.
Renelique v American Tr. Ins. Co. (2015 NY Slip Op 50482(U)) Appellate Term, Second DepartmentHolds under (a) (1) that the action is premature because the insurer timely requested verification and follow-up verification, had not received all requested material, and the provider did not show compliance before suit, so the 30-day period had not begun.
Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50080(U)) Appellate Term, Second DepartmentHolds under (a) that the claim is premature because the insurer proved timely initial and follow-up verification requests and nonreceipt, while the provider did not show compliance before suit, so the 30-day payment or denial period had not begun.
Right Solution Med. Supply, Inc. v NY Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 51860(U)) Appellate Term, Second DepartmentApplies (a) to find the first cause of action premature because timely requested verification remained outstanding and the provider did not show compliance before suit, so the insurer's 30-day period to pay or deny had not begun.
Coney Is. Physician Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51859(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the claims on four bills as premature because the insurer timely requested verification and follow-up verification, had not received the requested material, and the provider did not show compliance, so the 30-day period had not begun.
EMC Health Prods., Inc. v Geico Ins. Co. (2014 NY Slip Op 51834(U)) Appellate Term, Second DepartmentApplies (a) to find the action premature because the insurer had not received requested verification and the provider did not show it had supplied the material before suit, so the 30-day payment or denial period had not begun.
Skymed Med., P.C. v Tri-State Consumer Ins. (2014 NY Slip Op 51833(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature because the insurer proved timely initial and follow-up verification requests and nonreceipt, while the provider did not show compliance before suit, so the 30-day payment or denial period had not begun.
City Chiropractic, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51802(U)) Appellate Term, Second DepartmentHolds under (a) that the action is premature because the insurer established timely verification requests and outstanding verification, while the provider failed to show compliance before suit, so the 30-day period to pay or deny never began.
SS Med. Care, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51305(U)) Appellate Term, Second DepartmentHolds under (a) that outstanding verification prevented the 30-day period from beginning and made the action premature, where the insurer proved timely requests and nonreceipt of verification and the provider did not oppose dismissal.
Clinton Place Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50963(U)) Appellate Term, Second DepartmentRejects the insurer's claimed toll under (a) because its letters were insufficient verification requests, leaving it unable to establish timely denial of the fourteenth claim.
Favorite Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50467(U)) Appellate Term, Second DepartmentHolds under (a) that the action is premature because timely verification requests remained unanswered and the provider failed to show compliance before suit, so the insurer's 30-day period never began and dismissal was proper.
Elite Med. NY, P.C. v American Tr. Ins. Co. (2013 NY Slip Op 51738(U)) Appellate Term, Second DepartmentApplies (a) to dismiss a claim as premature because timely initial and follow-up verification requests remained unanswered when suit began, and the provider offered no opposing evidence.
Crotona Hgts. Med., P.C. v Clarendon Natl. Ins. Co. (2013 NY Slip Op 50473(U)) Appellate Term, Second DepartmentApplies (a) to dismiss one cause of action as premature where the insurer proved timely verification requests and the provider failed to show that it sent responsive information.
Compas Med., P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50251(U)) Appellate Term, Second DepartmentApplies (a) to hold four causes of action premature because timely initial and follow-up verification requests remained unanswered and the provider did not demonstrate compliance before suit, so the 30-day payment or denial period had not begun.
Compas Med., P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50249(U)) Appellate Term, Second DepartmentApplies (a) to hold four claims premature where the insurer established timely initial and follow-up verification requests and the provider failed to show compliance before suit, leaving the 30-day payment or denial period untriggered.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 50199(U)) Appellate Term, Second DepartmentApplies (a) to hold three claims premature because the insurer proved timely initial and follow-up requests for additional verification and the provider failed to demonstrate that it supplied all requested verification before suit.
Infinity Health Prods., Ltd. v Liberty Mut. Fire Ins. Co. (2012 NY Slip Op 52396(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature because the insurer's affidavit established timely initial and follow-up verification requests and nonresponse, and the provider never alleged that it responded, leaving the 30-day payment or denial period untriggered.
Essential Acupuncture Servs., P.C. v Amex Assur. Co. (2012 NY Slip Op 52259(U)) Appellate Term, Second DepartmentApplies (a) to find that the insurer failed to establish that its EUO condition-precedent defense escaped preclusion on two claims left unpaid and undenied beyond 30 days, with no EUO requested or pending during that period.
Oriental World Acupuncture, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 52181(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal as premature because timely initial and follow-up verification requests remained outstanding, and the provider did not show that it supplied verification before commencing suit.
Muhammad Tahir, M.D., P.C. v Travelers Prop. Cas. Ins. Co. (2012 NY Slip Op 51802(U)) Appellate Term, First DepartmentApplies (a) (1)'s verification toll where the insurer proved at trial that it timely mailed initial and follow-up requests to the provider's attorney, as authorized by counsel's correspondence, and awards dismissal.
AIM Acupuncture, P.C. v Travelers Ins. Co. (2012 NY Slip Op 51773(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature where the insurer's affidavits established timely initial and follow-up verification requests and nonreceipt of verification, and the provider failed to show compliance before suit, so the 30-day payment or denial period had not begun.
Quality Health Prods. v Country-Wide Ins. Co. (2012 NY Slip Op 51641(U)) Appellate Term, Second DepartmentApplies (a) to uphold dismissal as premature where the litigation supervisor established timely initial and follow-up verification requests and the provider failed to show compliance before suit, so the 30-day payment or denial period had not begun.
Dr. Stephen Matrangolo, D.C., P.C. v Encompass Indem. Co. (2012 NY Slip Op 51338(U)) Appellate Term, Second DepartmentApplies (a) to dismiss the action as premature because timely initial and follow-up verification requests remained unanswered when the provider sued, so the insurer's time to pay or deny had not elapsed.
Med-Tech Prod., Inc. v Progressive Northeastern Ins. Co. (2012 NY Slip Op 50930(U)) Appellate Term, Second DepartmentApplies (a) to uphold dismissal of two causes of action as premature because timely initial and follow-up verification requests remained unanswered before suit, so the insurer's 30-day payment or denial period had not begun.
MSSA Corp. v Praetorian Ins. Co. (2012 NY Slip Op 50413(U)) Appellate Term, Second DepartmentApplies (a) (1) in denying insurer summary judgment because the denial came after 30 days and the claims examiner failed to prove timely mailing of verification, leaving the insurer unable to show that its medical-necessity defense was not precluded.
Quality Psychological Servs., P.C. v MVAIC (2012 NY Slip Op 50404(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal because the insurer established nonreceipt of the claim and the provider failed to establish submission, so the time to pay or deny never began.
Jesa Med. Supply, Inc. v American Tr. Ins. Co. (2012 NY Slip Op 50052(U)) Appellate Term, Second DepartmentApplies (a) to hold the action premature because standard office procedures established timely mailing of initial and follow-up verification requests, the insurer showed nonreceipt, and the provider did not show compliance before suit, so the 30-day period had not begun.
Psychology YM, P.C. v Progressive Northeastern Ins. Co. (2011 NY Slip Op 52275(U)) Appellate Term, Second DepartmentApplies (a) to affirm dismissal as premature where timely mailed initial and follow-up verification requests remained unanswered when the provider commenced suit, so the insurer's time to pay or deny had not elapsed.
Jesa Med. Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 51603(U)) Appellate Term, Second DepartmentApplies (a) to hold two claims premature because verification requested from the provider and prescribing doctor remained outstanding when suit began, so the insurer's 30-day payment period had not started.
Omega Diagnostic Imaging, P.C. v MVAIC (2011 NY Slip Op 51259(U)) Appellate Term, First DepartmentApplies (a) (1) to find that a timely verification request tolled the payment-or-denial period despite the insurer's omitted follow-up, with limitations accrual occurring when the insurer denied after receiving the provider's response.
New Millenium Med. Supply v Clarendon Natl. Ins. Co. (2010 NY Slip Op51820(U)) Appellate Term, First DepartmentApplies (a) (1) to hold that the six-year limitations period began when the claim became overdue, here 30 days after receipt, rather than upon the insurer's untimely denial, requiring dismissal as time-barred.
Triangle R, Inc. v GEICO Ins. Co. (2010 NY Slip Op 50885(U)) Appellate Term, Second DepartmentApplies (a) to hold the action premature because the insurer proved timely mailing of initial and follow-up verification requests, and the provider did not demonstrate compliance before suit, leaving the 30-day payment-or-denial period unstarted.
Quality Rehab & P.T., P.C. v GEICO Ins. Co. (2010 NY Slip Op 50067(U)) Appellate Term, Second DepartmentApplies (a) (1) to hold the action premature because the provider did not demonstrate that it supplied verification before suit despite timely initial and follow-up requests, so the insurer's 30-day payment-or-denial period had not begun.
Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 50293(U)) Appellate Term, Second DepartmentApplies (a) (1) to deny the insurer's cross motion because denials were mailed more than 30 days after claim receipt without proof of verification tolling, leaving the insurer unable to establish that its medical-necessity defense was not precluded.
SZ Med., P.C. v Trumbull Ins. Co. (2007 NY Slip Op 50499(U)) Appellate Term, Second DepartmentApplies (a) (1) to reject the claimed verification toll because the insurer failed to prove mailing of its requests, rendering its denials untimely and precluding its fraudulent-billing defense.
Mid Atl. Med. P.C. v GEICO (2007 NY Slip Op 50014(U)) Appellate Term, Second DepartmentApplies (a) (1) to find the medical-necessity denial timely after receipt of requested verification, relying on competent mailing evidence, and permits the insurer's defense to raise a triable issue defeating the provider's summary judgment motion.
Commitment Med. Care, P.C. v State Farm Ins. Co. (2006 NY Slip Op 52117(U)) Appellate Term, First DepartmentApplies (a) (1) to find the denial timely within 30 days after the IME, using the provider's counsel's acknowledgment of receipt, and grants the insurer discovery on its medical-necessity and fraudulent-billing defenses.
Amaze Medical Supply Inc. v Allstate Ins. Co. (2004 NY Slip Op 51636(U)) Appellate Term, Second DepartmentApplies (a) to grant the provider summary judgment where complete proofs of claim established overdue payment and denials issued more than 30 days after submission precluded the insurer's medical-necessity defense.
Dilon Med. Supply Corp. v Travelers Ins. Co. (2005 NY Slip Op 25113) Trial courtApplies (a) (1) to treat the payment-or-denial period as not yet begun while a medical supplier left medical-necessity verification requests unanswered, rendering the action premature.
All-Boro Med. Supplies, Inc. v Progressive Northeastern Ins. Co. (2008 NY Slip Op 28207) Trial courtApplies (a) (1) to hold that claim receipt required the insurer to reschedule a previously arranged preclaim EUO within 30 days if it insisted on examination before payment or denial; failure to reschedule barred its EUO nonappearance defense.
Alpha Chiropractic P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 26498) Trial courtApplies (a) (1) to calculate interest from 30 days after receipt of each unpaid claim, rejecting accrual only from commencement of suit because the insurer stipulated that it had issued no denials.
Exclusive Med. Supply, Inc. v MVAIC (2012 NY Slip Op 50616(U)) Trial courtRelies on (a) (1)'s 30-day deadline in rejecting the insurer's contention that its qualification letter should be treated as a verification request tolling the time to pay or deny.
Elmont Open MRI & Diagnostic Radiology, P.C. v Country-Wide Ins. Co. (2007 NY Slip Op 27072) Trial courtApplies (a) (1), together with the interest regulation, to hold that interest runs from 30 days after claim receipt where payment is incomplete and no valid denial was issued within that period.
Montgomery Med., P.C. v State Farm Ins. Co. (2006 NY Slip Op 51116(U)) Trial courtApplies (a) (1) to deem EUO verification received on the examination date, holding denials issued 53 days later untimely and precluding the insurer's medical necessity and concurrent care defenses.
Liberty Mut. Ins. Co. v Brutus (2022 NY Slip Op 50799(U)) Trial courtApplies (a) (1) to hold that verification directed to the assignor about application misrepresentations also tolled the deadline for the provider's related bills, with the 30-day period running from receipt of the assignor's document response.
Andrew Lopedote, D.C. v General Assur. Co. (2004 NY Slip Op 50593(U)) Trial courtApplies (a)'s 30-day deadline where the insurer relied on preclaim IME requests and sought no verification from the provider, explaining that a legally insufficient stated denial ground entitles the provider to summary judgment.
Island Life Chiropractic Pain Care PLLC v Amica Mut. Ins. Co. (2019 NY Slip Op 51589(U)) Trial courtApplies (a) (1) in finding the insurer failed to establish a timely denial because it produced no verification request supporting the final-verification date stated in its denial.
New York Craniofacial Care, P.C. v Allstate Ins. Co. (2006 NY Slip Op 50500(U)) Trial courtRejects reading (a) (1) to make nonpayment alone sufficient for summary judgment, requiring the provider also to address whether the claims were timely and validly denied.
Ocean Diagnostic Imaging v Utica Mut. Ins. Co. (2004 NY Slip Op 50203(U)) Trial courtApplies (a) to grant the provider summary judgment because the insurer documented no timely verification requests capable of extending the 30-day payment-or-denial period.
American Tr. Ins. Co. v Nexray Med. Imaging PC (2023 NY Slip Op50538(U)) Trial courtHolds under (a) (1) that an unrequested Workers' Compensation Board decision did not constitute additional verification, rendering medical-necessity denials issued more than eight months after complete proof of claim ineffective and the defense precluded.
Medalliance Med. Health Servs. v Travelers Prop. Cas. Ins. Co. (2021 NY Slip Op 50737(U)) Trial courtApplies (a) (1) to find claims overdue and award the provider summary judgment because misaddressed verification requests did not toll the insurer's 30-day period.
Montvale Surgical Ctr., LLC. v State Farm Mut. Auto. Ins. Co. (2020 NY Slip Op 50106(U)) Trial courtApplies (a) (1) to deny the provider's summary judgment motion because the insurer's denial documents raised a factual issue about whether it timely denied the claims.
Neuro Rehab Med. Servs. of S.I., P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50671(U)) Trial courtApplies (a) (1) in finding that standard office mailing practices established timely mailing of denials within 30 days, supporting dismissal of claims based on two unexcused EUO nonappearances.
Central Park Physical Medicine & Rehab., P.C. v Travelers Indem. Co. of Conn. (2017 NY Slip Op 51354(U)) Trial courtApplies (a) (1) to uphold denials mailed within 14 days after the last scheduled EUO, finding the provider's later response letters untimely to challenge compliance with the EUO requests.
St. Barnabas Hosp. v Government Empls. Ins. Co. (2017 NY Slip Op 27056) Trial courtApplies (a) (1) to dismiss the hospital provider's claim as premature because its incomplete response and failure to answer a timely follow-up left verification of charges for necessary emergency health services outstanding, preventing the 30-day payment or denial period from beginning.
Advanced Neurological Care, P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 52203(U)) Trial courtApplies (a) (1)'s verification toll in denying both summary judgment motions because factual disputes over timely mailing and proper addressing remained; properly mailed requests would render the provider's action premature.
A.B. Med. Servs. PLLC v GEICO Gen. Ins. Co. (2008 NY Slip Op 52641(U)) Trial courtApplies (a) (1) to include a requested EUO in proof of claim and finds that timely verification requests tolled the 30-day period for six claims that the provider never fully verified.
Westchester Med. Ctr. v Mercury Cas. Co. (2008 NY Slip Op 28287) Trial courtApplies (a) (1) to hold the hospital's action premature because requested verification remained outstanding despite a timely follow-up, so the insurer's time to pay or deny had not expired.
West Tremont Med. Diagnostics P.C. v Travelers Indem. Co. (2005 NY Slip Op 51909(U)) Trial courtHolds that the denial issued months after receipt of verification was untimely under (a) (1), treating the insurer's issuance of a denial as inconsistent with its assertion that verification remained incomplete.
Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067) Court of AppealsCites (a) (1) for tolling the 30-day payment-or-denial period until requested verification arrives, in explaining the verification procedure the insurer failed to use to question the assignment.
Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co. (2009 NY Slip Op 00351) Appellate Division, Second DepartmentApplies (a) (1) to explain that, if the coded conditions were accident-related, the insurer had to pay or deny within 30 days; diagnosis codes without expert medical evidence did not raise a triable lack-of-coverage issue.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 02390) Appellate Division, Second DepartmentRelies on (a) (1)'s inclusion of requested verification in proof of claim when analyzing whether a hospital's UB-04 form was the functional equivalent of an NF-5.
Westchester Med. Ctr. v Countrywide Ins. Co. (2007 NY Slip Op 09024) Appellate Division, Second DepartmentApplies (a) to find that billing forms, biller affidavits and certified-mail documentation established receipt of proof of claim and the insurer's failure to pay or deny within 30 days, satisfying the provider's prima facie burden.
Mount Sinai Hosp. v Chubb Group of Ins. Cos. (2007 NY Slip Op 06650) Appellate Division, Second DepartmentCites (a) (1) to establish when benefits become overdue and quotes another decision's rule that payment or denial awaits all demanded verification, with an unanswered request rendering a provider's claim premature.
New York & Presbyt. Hosp. v Selective Ins. Co. of Am. (2007 NY Slip Op 06848) Appellate Division, Second DepartmentApplies (a) to find that proof of mailing the prescribed billing form and nonpayment within 30 days established the provider's prima facie entitlement to summary judgment, which the insurer failed to rebut.
New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. (2006 NY Slip Op 06223) Appellate Division, Second DepartmentApplies (a) (1) to recognize that the insurers' verification demand extended their time to pay or deny, making the partial denial timely because it followed receipt of verification within 30 days.
A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2012 NY Slip Op 06902) Appellate Division, Second DepartmentRelies on (a) (1)'s 30-day deadline following receipt of proof of claim or requested verification as part of the rule that an insurer's failure to deny timely generally precludes defenses to payment.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2011 NY Slip Op 08747) Appellate Division, Second DepartmentCites (a) for the rule that benefits are overdue if unpaid 30 days after receipt of proof of claim, including requested verification, in assessing the provider's prima facie entitlement to summary judgment.
Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 05680) Appellate Division, Second DepartmentRelies on (a) (1) in finding a triable issue over whether policy limits were exhausted by payment of claims for prior services during a verification toll, defeating the providers' summary judgment motion.
Countrywide Ins. Co. v 563 Grand Med., P.C. (2008 NY Slip Op 03059) Appellate Division, First DepartmentApplies (a) (1) to find the provider's prima facie entitlement to summary judgment from proof of mailed and received billing documents and overdue payment, before finding that the insurer raised a triable medical-justification issue.
Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 01319) Appellate Division, Second DepartmentApplies (a) (1) to explain that, because the provider sought summary judgment solely for failure to pay or deny within 30 days, the insurer needed only to raise a factual issue about timely denial.
Westchester Med. Ctr. v Clarendon Natl. Ins. Co. (2008 NY Slip Op 09786) Appellate Division, Second DepartmentApplies (a) (1) to find that evidence of neither payment nor denial within 30 days of receipt of prescribed claim forms established the provider's prima facie entitlement to summary judgment.
NYU-Hospital for Joint Diseases v Allstate Ins. Co. (2014 NY Slip Op 08613) Appellate Division, Second DepartmentRelies on (a) (1) for the rule that a timely and sufficient NF-10 issued within 30 days after receipt of an NF-5 satisfies the 30-day rule, explaining that nonprejudicial errors need not invalidate the denial.
Westchester Med. Ctr. v Allstate Ins. Co. (2014 NY Slip Op 00655) Appellate Division, Second DepartmentApplies (a) (1) to find the provider's prima facie entitlement to summary judgment based on proof that the insurer received the prescribed billing form and failed to pay or deny within 30 days.
Westchester Med. Ctr. v Country Wide Ins. Co. (2011 NY Slip Op 03838) Appellate Division, Second DepartmentApplies (a) (1) to the provider's prima facie showing of overdue benefits, but denies summary judgment because the insurer raises a triable issue about whether the provider fully complied with its verification demand.
Freligh v Government Empls. Ins. Co. (2018 NY Slip Op 00584) Appellate Division, Third DepartmentCites (a) (1) for the rule that an insurer need pay or deny only a verified claim, framing the remaining issue of whether the claimant's lost-wage claim was properly verified.
Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co. (2004 NY Slip Op 24527) Appellate Term, Second DepartmentDistinguishes (a) (1)'s postclaim verification rule, under which an unanswered timely IME request prevents the payment-or-denial period from beginning, from the insurer's rights following nonappearance at an IME requested before claim forms were submitted.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51776(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie showing that the third cause of action was premature, but the provider's owner's affidavit created a presumption of verification mailing and receipt, raising a factual issue that defeated dismissal of that claim.
S & M Supply Inc. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 50693(U)) Appellate Term, Second DepartmentCites (a) (1) to explain that EUO verification, like IME verification, is received on the examination date, while analyzing why the insurer's EUO requests failed to toll the claim deadline.
A.B. Med. Servs. PLLC v USAA Gen. Indem. Co. (2005 NY Slip Op 25297) Appellate Term, Second DepartmentDistinguishes the postclaim verification rules, including (a) (1), as inapplicable to preclaim IME requests, rejecting the providers' contention that those requests had to satisfy postclaim follow-up requirements.
A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 28528) Appellate Term, Second DepartmentCites (a) (1)'s overdue-benefits rule in explaining that allowing a provider to correct independent-contractor claim forms during litigation would inequitably expose the insurer to interest accruing 30 days after submission of the original forms.
Ocean Diagnostic Imaging P.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50525(U)) Appellate Term, Second DepartmentApplies (a) to find that untimely verification requests did not extend the insurer's 30-day claim-determination period, although the insurer could still assert that the injuries were unrelated to the accident.
King’s Med. Supply Inc. v Kemper Auto & Home Ins. Co. (2005 NYSlipOp 50450(U)) Appellate Term, Second DepartmentNotes that the denial satisfied (a) (1)'s 30-day deadline but its stated ground, failure to attend a post-claim IME, lacked merit because the insurer failed to send the required follow-up IME request.
Summit Psychological, P.C. v General Assur. Co. (2005 NY Slip Op 25263) Appellate Term, Second DepartmentRelies on (a) (1)'s inclusion of requested verification in proof of claim to explain why blanket denials issued before receipt of the provider's claims were invalid.
New Millennium Med. Imaging, P.C. v GEICO (2022 NY Slip Op 22300) Appellate Term, Second DepartmentRelies on (a) to identify when benefits become overdue and explains that, absent timely verification requests or payment or denial, the cause of action accrues 30 days after claim receipt.
Executive MRI Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 52250(U)) Appellate Term, Second DepartmentApplies (a) (1) to find a verification request issued 66 days after claim receipt untimely, leaving the denial late and most defenses precluded, while preserving the defense that the injuries lacked a causal nexus to the accident.
Shtarkman v Allstate Ins. Co. (2005 NYSlipOp 51028(U)) Appellate Term, Second DepartmentQuotes (a) (1)'s rule that benefits become overdue 30 days after receipt of proof of claim, including requested verification, as support for rejecting a blanket denial issued before the provider's claim was received.
Healthy Way Acupuncture, P.C. v Clarendon Natl. Ins. Co. (2017 NY Slip Op 50345(U)) Appellate Term, First DepartmentApplies (a) (1) to reject the provider's untimeliness argument because timely verification and follow-up requests tolled the 30-day period; insurer summary judgment nevertheless failed for insufficient proof that the charges exceeded the fee schedule.
Arco Med. NY, P.C. v Metropolitan Cas. Ins. Co. (2013 NY Slip Op 52001(U)) Appellate Term, Second DepartmentRelies on (a) to find that four EUO nonappearance denials issued within 30 days of claim receipt were timely, supporting dismissal of those claims on the ground that the provider failed to appear for duly scheduled EUOs.
Devonshire Surgical Facility, L.L.C. v Hereford Ins. Co. (2010 NY Slip Op 52297(U)) Appellate Term, First DepartmentApplies (a) (1) to uphold the finding that the insurer timely mailed its denials within 30 days, while requiring the summary judgment motions to await a determination of workers' compensation coverage.
New Way Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51678(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie showing that the second cause of action was premature, but the provider's employee's affidavit created a presumption of verification mailing and receipt, raising a factual issue that defeated dismissal of that claim.
Bronx Multi Med. Care, P.C. v Kemper Cas. Ins. Co. (2008 NY Slip Op 51928(U)) Appellate Term, First DepartmentRelies on (a) (1) in finding that proof of mailed and received billing forms and overdue benefits established the provider's prima facie entitlement to summary judgment; the insurer's unsigned peer-review report failed to raise a triable issue.
Mollins v Allstate Ins. Co. (2008 NY Slip Op 51616(U)) Appellate Term, First DepartmentRelies on (a) (1) in finding that mailed and received billing forms and overdue benefits established prima facie entitlement to partial summary judgment; the insurer submitted neither its underlying IME report nor other evidence supporting lack of medical necessity.
Compas Med., P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51000(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie showing that requested verification was not received, but the provider's owner's affidavit created a presumption of mailing and receipt, raising a factual issue on the fourth through sixth causes of action.
Vladenn Med. Supply Corp. v Travelers Ins. Co. (2016 NY Slip Op 50381(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie prematurity showing based on unreceived verification, but the provider's employee's affidavit created a presumption of mailing and receipt, raising a factual issue that defeated dismissal.
Tam Med. Supply Corp. v American Tr. Ins. Co. (2016 NY Slip Op 50369(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie prematurity showing based on unreceived verification, but the provider's owner's affidavit created a presumption of mailing and receipt, raising a factual issue that defeated dismissal.
Emc Health Prods., Inc. v National Liab. & Fire Ins. Co. (2016 NY Slip Op 50132(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie prematurity showing, but the provider's employee's affidavit created a presumption that verification was mailed and received, defeating dismissal of the first, second, third and fifth causes of action.
J.C. Healing Touch Rehab, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 50033(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie prematurity showing, but an affidavit from the provider's billing company's employee created a presumption of verification mailing and receipt, defeating dismissal of the first and third through sixth causes of action.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51699(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie showing that the first cause of action was premature, but the provider's owner's affidavit created a presumption of verification mailing and receipt, raising a factual issue that defeated dismissal of that claim.
T & J Chiropractic, P.C. v American Tr. Ins. Co. (2015 NY Slip Op 51673(U)) Appellate Term, Second DepartmentRelies on (a) for the insurer's prima facie prematurity showing based on unreceived verification, but the provider's owner's affidavit created a presumption of mailing and receipt, raising a factual issue that defeated dismissal.
New Way Med. Supply Corp. v Praetorian Ins. Co. (2015 NY Slip Op 51632(U)) Appellate Term, Second DepartmentApplies (a) to find a prima facie showing of prematurity based on timely verification requests and nonreceipt, but finds the provider's owner's affidavit sufficient to raise a presumption that the verification was mailed and received.
Longevity Med. Supply, Inc. v Praetorian Ins. Co. (2015 NY Slip Op 50401(U)) Appellate Term, Second DepartmentApplies (a) to find a prima facie showing that the second cause of action is premature for outstanding verification, but finds the provider's employee affidavit raises a presumption of mailing and receipt, leaving a triable issue.
Utopia Equip., Inc. v NY Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 51820(U)) Appellate Term, Second DepartmentRelies on (a) to find denials of two claims timely mailed, supporting summary judgment dismissing those claims upon proof that the assignor failed to appear for duly scheduled IMEs.
NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U)) Appellate Term, First DepartmentApplies (a) (1) to find the providers made a prima facie showing through proof of mailing, receipt, and overdue payment; their summary judgment award stands because the insurer supplied no evidence supporting its timely medical necessity denial.
Infinity Health Prods., Ltd. v Travelers Ins. Co. (2013 NY Slip Op 50253(U)) Appellate Term, Second DepartmentCites (a) in finding a later bill timely denied within 30 days of receipt based on the provider's failure to attend two previously requested EUOs concerning the same accident and assignor.
OS Tigris Acupuncture, P.C. v Liberty Mut. Insurance Co. (2008 NY Slip Op 51996(U)) Appellate Term, First DepartmentApplies (a) (1) to find the provider's prima facie showing established by evidence that prescribed billing forms were mailed and received and payment was overdue, before rejecting the insurer's inadmissible medical-necessity evidence.
Statewide Med. Acupuncture Servs., PC v Travelers Ins. Co. (2005 NY Slip Op 51773(U)) Trial courtCites (a) (1) in explaining that defenses not asserted within 30 days are generally waived unless verification tolls the deadline, before considering whether alleged provider incorporation fraud survives an untimely denial.
King’s Med. Supply Inc. v Country-Wide Ins. Co. (2004 NY Slip Op 24394) Trial courtCites (a) (1) for the insurer's 30-day payment-or-denial deadline under both the old and revised regulations, as part of the framework for evaluating a medical supplier's claim and the insurer's verification objections.
Dynamic Med. Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 20285) Trial courtRelies on (a) (1) to treat a properly demanded EUO as verification, with 30 days to pay or deny running from the examination, in rejecting advance demands for corporate and financial documents.
Pro-Align Chiropractic, P.C. v Travelers Prop. Cas. Ins. Co. (2017 NY Slip Op 27415) Trial courtRelies on (a) for the insurer's duty to pay, deny, or seek further verification upon an arguably responsive verification submission, stating that silence in response waives defenses.
Lender Med. Supply, Inc. v Hartford Ins. Co. (2012 NY Slip Op 50903(U)) Trial courtCites (a) (1) to support the quoted rule that payment or denial awaits demanded verification, and explains that an untimely follow-up defeats tolling and precludes a defense based on failure to provide verification, including post-claim EUO nonappearance.
East Coast Acupuncture, P.C. v Hereford Ins. Co. (2016 NY Slip Op 26042) Trial courtCites (a) (1) as the ordinary 30-day overdue-benefits rule, explaining that the amended fee schedule provision creates an exception allowing the insurer to assert overbilling despite a late denial.
Saddle Brook Surgicenter, LLC v All State Ins. Co. (2015 NY Slip Op 25099) Trial courtQuotes (a) (1)'s 30-day rule and notes that the insurer undisputedly failed to deny within that period, before addressing whether the amended excessive-fee provision nevertheless permits its fee-schedule defense.
Cambridge Med., P.C. v Progressive Cas. Ins. Co. (2010 NY Slip Op 20272) Trial courtRelies on (a) (1) for the rule that the 30-day payment-or-denial period follows receipt of all requested verification, in rejecting a requirement to notify the assignor when following up on verification requested from the provider.
Pine Hollow Med., P.C. v Global Liberty Ins. Co. of N.Y. (2009 NY Slip Op 29264) Trial courtCites (a) (1) for the rule that the insurer must pay or deny within 30 days after receiving all requested verification, in considering whether a follow-up sent one day late defeats tolling.
Uniondale Chiropractic Off. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 51687(U)) Trial courtQuotes (a) (1)'s definition of overdue benefits as part of the provider's prima facie summary judgment burden, requiring proof that billing forms were mailed and received and benefits remained unpaid beyond 30 days.
Sea Side Med., P.C. v State Farm Mut. Auto Ins. Co. (2006 NY Slip Op 26246) Trial courtCites (a) (1) for the 30-day payment-or-denial requirement and preclusion of most defenses upon noncompliance, as the framework for determining whether an early verification follow-up preserved tolling of the deadline.
HKP Physical Therapy, P.C. v Government Empls. Ins. Co. (2019 NY Slip Op 29381) Trial courtRelies on (a) (1) to support dismissal as premature where the provider has not fully answered timely verification requests, while requiring good cause for requests investigating eligibility for reimbursement.
Garden State Anesthesia Assoc., PA v Progressive Cas. Ins. Co. (2013 NY Slip Op 23332) Trial courtApplies (a) to treat EUO verification as received when the assignor appeared, giving the insurer 30 days from that examination to pay or deny the provider's claims unless another toll or extension applied.
Park Slope Med. & Surgical Supply, Inc. v Country-Wide Ins. Co. (2008 NY Slip Op 51063(U)) Trial courtCites (a) (1) for the rule that a claim need not be paid or denied until all demanded verification is supplied, as support for tolling while requested verification remains outstanding.
American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U)) Trial courtRelies on the rule quoted from precedent under (a) (1) that requested verification tolls the 30-day period, in rejecting substantial compliance as a substitute for furnishing all relevant verification.
MSB Physical Therapy, P.C. v Nationwide Ins. (2021 NY Slip Op 50750(U)) Trial courtRelies on (a) (1) to reason that preclaim EUO requests cannot toll the 30-day payment-or-denial period because tolling depends on verification requests governed by the claims-processing rules.
Liberty Mut. Ins. Co. v Carranza (2021 NY Slip Op 50284(U)) Trial courtRelies on (a) (1)'s 30-day deadline after receipt of requested verification to reject an interpretation exempting examinations prompted by provider bills from the deadlines for requesting and scheduling EUOs and IMEs.
Tyorkin v Garrison Prop. & Cas. Ins. Co. (2016 NY Slip Op 50846(U)) Trial courtCites (a) for the 30-day payment-or-denial requirement, then holds the insurer's defense precluded because it issued no denial of claim form.
Dynamic Med. Imaging, P.C. v State Farm Fire & Cas. Co. (2011 NY Slip Op 21210) Trial courtRelies on (a) (1)'s rule that EUO verification is received on the examination date to treat EUO attendance as part of verification, in discussing why the provider need not plead or prove EUO compliance.
A.M. Med. Servs., P.C. v Deerbrook Ins. Co. (2008 NY Slip Op 50368(U)) Trial courtRelies on (a) (1)'s payment deadline and verification tolling rules to reject requiring further medical records where the insurer's experts had sufficient information to assess medical necessity, reasoning that additional verification would unnecessarily prolong claim determination.
Westchester Med. Ctr. v Encompass Ins. Co. (2007 NY Slip Op 52475(U)) Trial courtCites (a) (1)'s 30-day overdue-benefits rule in assessing the provider's motion for summary judgment on its unpaid hospital claim.
Westchester Med. Ctr. v Allstate Ins. Co. (2007 NY Slip Op 52257(U)) Trial courtApplies (a) (1) to find a prima facie showing for the unpaid hospital-bill balance from evidence of claim receipt and failure to pay or deny within 30 days, shifting the burden to the insurer to raise factual issues.
DWP Pain Free Med. P.C. v Progressive Northeastern Ins. Co. (2006 NY Slip Op 26531) Trial courtCites (a) (1) for the rule that the 30-day payment-or-denial period does not begin until all demanded verification is provided, as the framework for assessing whether electronic signatures satisfied the insurer's verification demand.
A.B. Med. Servs. PLLC v Farm Family Cas. Ins. Co. (2004 NY Slip Op 24346) Trial courtCites (a) (1) for measuring the 30-day payment-or-denial period from receipt of requested verification, as part of the framework for determining the providers' prima facie entitlement to summary judgment.
New York Craniofacial Care v Lumbermen’s Mut. Cas. Co. (2004 NY Slip Op 24025) Trial courtDistinguishes (a) (1)'s express inclusion of EUOs from the former regulations governing the claim, which mentioned only medical examinations, explaining that the EUO provisions took effect after the relevant claim period.
Baldwin Med. Servs., P.C. v Maya Assur. Co (2026 NY Slip Op 51329(U)) Trial courtCites (a) (1)'s 30-day payment-or-denial deadline as the framework for evaluating verification tolling; the insurer failed to establish timely, proper mailing of its initial verification request.
ENS Med., P.C. v Nationwide Ins. Co. (2026 NY Slip Op 26033) Trial courtRelies on (a) (1)'s treatment of EUOs as claim verification to reason that reimbursement of a provider's lost earnings from attending an insurer-demanded EUO falls within disputes subject to arbitration.
Queens Radiology Imaging v GEICO (2025 NY Slip Op 51823(U)) Trial courtRelies on (a) (1)'s treatment of an EUO as verification while explaining that a timely request for additional information may extend the 30-day pay-or-deny period despite completion of the EUO.
Titan Diagnostic Imaging Servs. Inc. v State Farm Mut. Auto Ins. Co (2024 NY Slip Op 24209) Trial courtCites (a) (1) for tolling the 30-day payment-or-denial period through a timely verification demand, in addressing the provider's objection that the insurer's time had expired.
Liberty Mut. Ins. Co. v Anderson (2023 NY Slip Op 50746(U)) Trial courtApplies (a) (1) to count the denial period by adding the time before the first verification request to the two days after verification was completed, treating EUO verification as received on the examination date.
Kolb Radiology, P.C. v Hereford Ins. Co. (2022 NY Slip Op 22089) Trial courtCites (a) for the 30-day payment deadline and explains that timely additional verification may extend it, in addressing the provider's refusal to supply requested MRI films without advance payment of reproduction costs.
Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims (2021 NY Slip Op 50523(U)) Trial courtQuotes (a) (1) to explain that proof of claim includes all relevant requested verification, supporting the rule that timely verification requests toll the insurer's payment-or-denial period.
Precise Physical Therapy Solutions v State Farm Mut. Auto. Ins. Co. (2020 NY Slip Op 20254) Trial courtQuotes (a) (1)'s rule deeming EUO verification received on the examination date in assessing whether failure to return a signed transcript justifies dismissal.
New Chiropractic Care, P.C. v Nationwide Ins. Co. of N.Y. (2020 NY Slip Op 50652(U)) Trial courtRelies on (a) (1) to reason that preclaim verification requests cannot toll the payment-or-denial period because tolling depends on requests governed by the claims-processing rules, while recognizing conflicting authority on preclaim EUO requests.
Dassa Orthopedic Med. Servs. PC v Amica Mut. Ins. Co. (2019 NY Slip Op 51664(U)) Trial courtApplies (a) to find the provider's bills overdue, but grants only partial summary judgment establishing timely submission and absence of a denial because a factual issue remains over whether New Jersey law governs.
Right Aid Med. Supply, Corp. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 27181) Trial courtCites (a) (1) for the rule that a claim need not be paid or denied until all demanded verification is provided, in addressing the insurer's burden to prove that verification remained outstanding.
Westchester Med. Ctr. v Travelers Prop. Cas. Co. of Am. (2014 NY Slip Op 51216(U)) Trial courtCites (a) (1)'s 30-day deadline after receipt of proof of claim, including requested verification, when evaluating the insurer's argument that treatment allegedly unrelated to the accident allowed it to deny outside that period.
Meridian Psychological Servs., PC v Government Empls. Ins. Co. (2014 NY Slip Op 24177) Trial courtCites (a) (1) for the rule that timely and properly requested verification tolls the insurer's time to pay or deny, in considering continued nonpayment after receipt of a completed but unsigned NF-2.
Boulevard Multispec Med., P.C. v Tri-State Consumer Ins. Co. (2014 NY Slip Op 24080) Trial courtRelies on (a) to treat an IME as claim verification, deemed received when performed, in explaining the IME's role in verifying injuries, condition, and the need for further treatment or testing.
Elmont Open MRI & Diagnostic Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 22242) Trial courtRelies on (a) (1) for the provider's prima facie requirement to show timely claim submission and failure to pay or deny within 30 days, when considering summary judgment for the provider upon searching the record.
MVAIC v Stand-Up MRI of Manhattan, P.C. (2011 NY Slip Op 51187(U)) Trial courtCites (a) (1) for the rule that the 30-day period awaits demanded verification, while explaining that verification does not remain outstanding merely because the insurer received only some requested material.
Mount Sinai Hosp. v State Farm Mut. Auto. Ins. Co. (2011 NY Slip Op 51423(U)) Trial courtCites (a) (1) for the 30-day pay-or-deny rule and states that an insurer that misses the deadline may still assert lack of coverage, but rejects that defense on the merits and grants the hospital summary judgment.
Motor Veh. Acc. Indem. Corp. v Physical Medicine & Rehab of NY (2011 NY Slip Op 50848(U)) Trial courtCites (a) (1) for the insurer's 30-day payment-or-denial obligation and recounts the arbitrator's preclusion finding where the insurer neither paid, denied, nor sought verification within that period.
Westchester Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 20512) Trial courtRelies on (a) (1) in recognizing the provider's prima facie showing of overdue payment, while finding that verification requests tolled the period and the insurer thereafter timely denied the claim on intoxication or felony grounds.
Media Neurology, P.C. v Liberty Mut. Ins. Co. (2009 NY Slip Op 51424(U)) Trial courtCites (a) (1)'s 30-day payment-or-denial rule in explaining that a fraud defense must be raised in a timely denial before it can justify the requested discovery.
Ocean Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2009 NY Slip Op 50565(U)) Trial courtApplies (a) to find that the insurer neither paid nor denied within 30 days, while recognizing that this failure does not preclude its lack-of-coverage defense.
MVAIC v Astro Med. Care P.C. (2009 NY Slip Op 50509(U)) Trial courtApplies (a) (1)'s 30-day requirement to the insurer, finding most defenses precluded because it neither timely denied the claim nor timely requested verification.
All-Boro Med. Supplies, Inc. v Progressive Northeastern Ins. Co. (2008 NY Slip Op 50766(U)) Trial courtCites (a) (1) for the 30-day overdue-benefit rule and quotes another decision for the proposition that payment or denial awaits all demanded verification, supporting the rule that unanswered proper verification makes a provider's claim premature.
KOI Med. Acupuncture v State Farm Ins. Co. (2007 NY Slip Op 51705(U)) Trial courtCites (a) (1) in reasoning that, assuming admissible proof of claim submission, failure to pay or deny timely satisfies the provider's prima facie case, while an untimely denial does not waive a staged-accident coverage defense.
New York Hosp. Med. Ctr. of Queens v Liberty Mut. Ins. Co. (2007 NY Slip Op 51256(U)) Trial courtCites (a) (1) for the provider's prima facie burden to establish proper claim submission and the insurer's failure to pay or issue a valid denial within 30 days of receipt.
Fair Price Med. Supply Corp. v Travelers Indem. Co. (2008 NY Slip Op 04946) Court of AppealsQuotes another decision citing (a) (1) for tolling the 30-day pay-or-deny period until the insurer receives requested verification, as background to the dispute over preclusion of a nondelivery defense.
Government Employees Ins. Co. v Mayzenberg (2025 NY Slip Op 06527) Court of AppealsCites (a) (1) as background to the provider-eligibility dispute, explaining that failure to pay or deny within 30 days after proof of claim can expose the insurer to interest and attorney's fees.
East Acupuncture, P.C. v Allstate Ins. Co. (2009 NY Slip Op 01191) Appellate Division, Second DepartmentQuotes (a) (1)'s rule that benefits become overdue 30 days after receipt of proof of claim as background to the dispute over interest accrual on the provider's untimely denied claims.
Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 05779) Appellate Division, Second DepartmentQuotes another decision's explanation that (a) (1) includes requested verification in proof of claim and that receipt of a completed NF-5 triggers the insurer's 30-day period to pay, deny, or seek verification.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2008 NY Slip Op 04866) Appellate Division, Second DepartmentNotes the provider's argument under (a) (1) that benefits were overdue because the insurer failed to pay or deny within 30 days of claim receipt.
Inwood Hill Med. v Allstate Ins. Co. (2004 NY Slip Op 50565(U)) Trial courtCites (a) (1) for the 30-day overdue-benefits rule in explaining the claims-processing framework governing the providers' summary judgment motion.
Complete Orthopedic Supplies, Inc. v State Farm Ins. Co. (2007 NY Slip Op 27192) Trial courtCites (a) (1) in a background explanation that failure to pay within 30 days permits suit on an overdue claim, while a timely denial preserves the stated objections for litigation.
Prime Psychological Servs., P.C. v Nationwide Prop. & Cas. Ins. Co. (2009 NY Slip Op 29100) Trial courtQuotes another decision, citing (a) (1), for the rule that payment or denial awaits verification, then notes that both EUO scheduling letters preceded receipt of the provider's claim.
Victory Med. Diagnostics, P.C. v Nationwide Prop. & Cas. Ins. Co. (2012 NY Slip Op 22149) Trial courtCites (a) for the 30-day payment or denial deadline following receipt of a claim or verification, as background to the insurer's argument that outstanding corporate documents rendered the provider's action premature.
Prime Psychological Servs., PC v ELRAC, Inc. (2009 NY Slip Op 52579(U)) Trial courtCites (a) (1) alongside a quotation from another decision that a claim need not be paid or denied until all demanded verification is provided, when discussing follow-up requirements for post-claim IMEs.
Bayside Rehab & Physical Therapy, P.C. v GEICO Ins. Co. (2009 NY Slip Op 29145) Trial courtQuotes another decision, citing (a) (1), for the postclaim rule that payment or denial awaits all demanded verification, while examining whether verification notice requirements apply to IMEs conducted before any claim is submitted.
Carle Place Chiropractic v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 51065(U)) Trial courtQuotes (a) (1)'s definition of overdue benefits alongside the statutory definition and appellate authority recognizing that failure to pay within 30 days renders benefits overdue.
Viviane Etienne Med. Care PC v Country-Wide Ins. Co. (2018 NY Slip Op 28058) Trial courtQuotes an earlier appellate ruling citing (a) (1) that mailed and received prescribed billing forms, coupled with the insurer's failure to timely pay or deny, established the provider's prima facie entitlement to judgment.
Lincoln Gen. Ins. Co. v Alev Med. Supply Inc. (2009 NY Slip Op 29389) Trial courtCites (a) (1)'s 30-day payment-or-denial deadline and explains that timely verification requests can toll that period in the insurer's action to recover benefits already paid.
Travelers Indem. Co. v Parisien (2020 NY Slip Op 51561(U)) Trial courtNotes the insurers' allegation under (a) (1) that they timely requested EUOs and the provider failed to appear, in support of their request for declaratory relief.
Greater Forest Hills Physical Therapy, PC v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51594(U)) Trial courtQuotes an agency opinion invoked by the insurer stating that (a) (1) requires payment or denial within 30 days after proof of claim, even for treatment claims submitted after an IME-based denial of future benefits.
Tarnoff Chiropractic, P.C. v GEICO Ins. Co. (2012 NY Slip Op 50670(U)) Trial courtQuotes (a) (1) to explain that EUO verification is received on the examination date, giving the insurer 30 days from the EUO to pay or deny, in discussing the need for an objectively justified EUO request.
Amato v State Farm Ins. Co. (2010 NY Slip Op 20431) Trial courtCites (a) (1) for the 30-day payment-or-denial rule and tolling through timely IME, EUO, or verification demands, in discussing the insurer's reliance on an IME cutoff.
T&G Med. Supplies, Inc. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 50636(U)) Trial courtCites (a) (1) for the 30-day payment-or-denial rule before distinguishing untimely disclaimers from a lack-of-coverage defense.
Blano Med., P.C. v Hereford Ins. Co (2025 NY Slip Op 51540(U)) Trial courtQuotes another decision's reliance on (a) (1)'s 30-day payment deadline in treating fee schedule overcharges as an exception, an interpretation it rejects.
State Farm Mut. Auto. Ins. Co. v Sweetwater Chiropractic, P.C. (2018 NY Slip Op 51177(U)) Trial courtNotes the insurers' allegation that EUOs were timely requested under (a) (1) and that the provider's nonappearance breached a condition precedent, as the basis for their request for a declaration of no coverage.
NY Rehab Pain Mgt. & Med. Servs., PC v State Farm Auto Ins. Co. (2016 NY Slip Op 50821(U)) Trial courtCites (a) (1) for the rule that the 30-day payment or denial period does not begin until requested verification, including performance of a requested EUO, is received, in explaining the insurer's EUO nonappearance defense.
Acuhealth Acupuncture, P.C. v New York City Tr. Auth. (2016 NY Slip Op 50297(U)) Trial courtQuotes another decision's discussion of (a) (1)'s rule that benefits become overdue 30 days after receipt of proof of claim, including requested verification, when considering payment priority and arbitral authority to award beyond policy limits.
Quality Psychological Servs., P.C. v Hartford Ins. Co. (2013 NY Slip Op 50045(U)) Trial courtQuotes another decision treating an EUO as verification under (a) (1), deemed received on the examination date, in discussing EUO attendance as a condition precedent to payment.
Star Med. Servs., P.C. v Allstate Ins. Co. (2004 NY Slip Op 24410) Trial courtNotes the provider's argument under (a) that the denial of the driver's treatment claim was untimely because it was not received within 30 days, opposed by the insurer's contention that verification requests tolled that period.
SCOB, LLC v Liberty Mut. Ins. Co. (2026 NY Slip Op 51484(U)) Trial courtCites (a) (1) for verification tolling of the 30-day payment-or-denial period in outlining the rules governing the insurer's IME nonappearance defense.
Pedro Torres-Jimenez, MD PC v Nationwide Affinity Ins. Co. of Am. (2026 NY Slip Op 50073(U)) Trial courtNotes the provider's reliance on (a) (1), which deems EUO verification received on the examination date, to oppose the insurer's summary judgment motion based on outstanding post-EUO verification.
Cuevas v Everest Denali Ins. Co. (2025 NY Slip Op 52120(U)) Trial courtNotes the claimant's argument that (a) (1) made the disclaimer untimely because it was issued almost eight months after the EUO, when proof of claim was deemed received.
Big Apple Med. Supply, Inc. v Nationwide Affinity Ins. Co. of Am. (2018 NY Slip Op 51659(U)) Trial courtQuotes an earlier decision's rule that payment or denial awaits all demanded verification, citing (a) (1), before addressing whether the insurer proved nonreceipt of the requested verification through admissible evidence.
Lenox Hill Radiology v Global Liberty Ins. Co. of N.Y. (2017 NY Slip Op 50978(U)) Trial courtCites (a) (1) for the 30-day payment-or-denial deadline and the toll until requested verification is received, as the framework for evaluating the insurer's contention that outstanding verification made the claims premature.
Global Liberty Ins. Co. v Jonathan Lewin, M.D., P.C. (2017 NY Slip Op 50897(U)) Trial courtQuotes another decision citing (a) (1) for the 30-day payment-or-denial deadline, in addressing the insurer's contention that unreceived MRI films left verification outstanding.
Zwanger & Pesiri Radiology Group, LLP v Mapfre Ins. Co. (2017 NY Slip Op 50981(U)) Trial courtCites (a) (1) for the 30-day payment-or-denial deadline as the starting point for assessing whether verification requests tolled that period in the insurer's motion based on unsupplied verification.
Alleviation Med. Servs., PC v Hertz Co. (2015 NY Slip Op 25285) Trial courtQuotes another decision citing (a) (1) for tolling the 30-day period until requested verification arrives, in discussing the provider's burden to establish an overdue claim through admissible evidence of submission.
Back to Back Chiropractor, P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 51088(U)) Trial courtCites (a) (1) for the rule that a claim is overdue if not paid or denied within 30 days after receipt of proof of claim, as background to the insurer's verification and EUO defenses.
Perfect Point Acupuncture, P.C. v Auto One Ins. Co. (2010 NY Slip Op 50010(U)) Trial courtCites (a) (1) for the 30-day payment-or-denial rule and preclusion of most defenses for noncompliance, before addressing whether an early IME follow-up preserved the insurer's verification toll.
Jesa Med. Supply, Inc. v GEICO Ins. Co. (2009 NY Slip Op 29386) Trial courtCites (a) (1)'s 30-day payment-or-denial rule before finding that the provider established mailing of its claims in support of its summary judgment motion.
New York Hosp. Med. Ctr. of Queens v Countrywide Ins. Co. (2009 NY Slip Op 50764(U)) Trial courtQuotes (a) (1) to explain when unpaid hospital claims become overdue in an action seeking payment of no-fault benefits.
Lenox Hill Radiology MIA, P.C. v American Tr. Ins. Co. (2008 NY Slip Op 28053) Trial courtNotes the insurer's argument under (a) (1) that benefits were not overdue because the provider had not supplied requested medical-necessity verification.
Dennis v Allstate Ins. Co. (2008 NY Slip Op 50654(U)) Trial courtCites (a) for the requirement that proof of claim include all relevant requested verification before unpaid benefits become overdue after 30 days, while discussing the claimant's prima facie burden on a motion to vacate dismissal.
Star Med. Servs., P.C. v Allstate Ins. Co. (2004 NY Slip Op 51280(U)) Trial courtNotes the provider's argument under (a) that the denials were not received within 30 days after the insurer received the claims, including a claim denied for failure to attend an EUO.

Subdivision (b) (85 decisions)

A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636) Appellate Division, Second DepartmentHolds that (b) (4) requires release of a medical examination or peer review report upon written request and does not require the insurer to include a medical rationale in a denial based on lack of medical justification.
New York Univ. Hosp. Rusk Inst. v Government Empls. Ins. Co. (2007 NY Slip Op 03671) Appellate Division, Second DepartmentHolds that (b) (4) requires release of a medical examination or peer review report upon written request, but does not require the medical rationale in the denial form, rejecting that ground for granting the provider summary judgment.
Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979) Appellate Division, Second DepartmentApplies (b) to find the denial timely when measured from receipt of additional verification allegedly revealing workers' compensation eligibility, defeating the provider's summary judgment motion despite denial more than 30 days after the initial claim.
A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co. (2007 NY Slip Op 03635) Appellate Division, Second DepartmentHolds that (b) (4) requires release of an IME or peer review report upon written request and does not require the medical rationale in the denial form, rejecting a challenge to the forms' sufficiency.
New York Univ. Hosp.-Tisch Inst. v Government Empls. Ins. Co. (2014 NY Slip Op 03812) Appellate Division, Second DepartmentHolds under (b) (4) that absent a written request the insurer need not furnish a peer review report, in admissible form or otherwise, so the report's inadmissibility did not warrant summary judgment for the providers.
Chapa Prods., Corp. v MVAIC (2026 NY Slip Op 00342) Appellate Division, Second DepartmentHolds that (b) (3) permits denial for outstanding verification after 120 days but sets no deadline for that denial, rejecting preclusion based on failure to deny within the next 30 days and reinstating summary judgment for the insurer.
Hereford Ins. Co. v 21 Century Chiropractic Care (2025 NY Slip Op 06022) Appellate Division, First DepartmentApplies (b) (3) to reject reliance on subscribed EUO transcripts supplied years after timely subscription demands, explaining that denial is permitted after 120 days without required verification or a valid written excuse.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U)) Appellate Term, Second DepartmentCites (b) (4) in holding a timely medical-necessity denial ineffective and the defense precluded because the denial lacked peer review or other proof supplying a sufficiently detailed factual basis and medical rationale.

Show all 85 decisions

Alleviation Med. Servs., P.C. v Allstate Ins. Co. (2017 NY Slip Op 27097) Appellate Term, Second DepartmentApplies (b) (3) to treat the insurer's denial as an implicit declaration that the claim was fully verified, rejecting policy exhaustion based on later payments because fully verified claims are payable in the order received.
Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 50623(U)) Appellate Term, Second DepartmentApplies (b) (3) to affirm dismissal where the insurer denied receiving any requested documents and the provider's qualified assertion of mailing failed to raise a triable issue of compliance or reasonable justification for noncompliance.
CPM Med Supply, Inc. v State Farm Fire & Cas. Ins. Co. (2019 NY Slip Op 50576(U)) Appellate Term, Second DepartmentHolds under (b) (3) that a provider's view that requested invoices are unnecessary does not reasonably justify withholding them, finding denial after 120 days proper but affirming dismissal as premature because the insurer did not cross-appeal.
Chapa Prods. Corp. v MVAIC (2019 NY Slip Op 29341) Appellate Term, Second DepartmentHolds that (b) (3) permits, but does not require, denial for incomplete verification after 120 days; because verification remained incomplete and the denials were untimely, dismisses the action as premature without prejudice rather than with prejudice.
King’s Med. Supply Inc. v Kemper Auto & Home Ins. Co. (2005 NYSlipOp 50450(U)) Appellate Term, Second DepartmentApplies (b) (3) to deny summary judgment on a claim with outstanding verification because the insurer's mailing proof raised a triable issue whether its verification requests were timely mailed.
Park Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U)) Appellate Term, Second DepartmentApplies (b) (4) to recognize a sufficiently detailed peer review as a basis for a medical-necessity defense, finding the insurer's affirmed file-based review raised a triable issue and defeated the provider's summary judgment motion.
King’s Med. Supply Inc. v Allstate Ins. Co. (2005 NYSlipOp 50451(U)) Appellate Term, Second DepartmentRelies on (b) (3) to explain that outstanding verification postpones payment or denial, but denials for missing physician narratives are premature if the insurer has not exhausted the verification procedures.
A.b. Med. Servs. Pllc v Cna Ins. Co. (2004 NY Slip Op 50061(U)) Appellate Term, First DepartmentApplies (b) (4) to reject the provider's challenge to peer review as a basis for a medical-necessity defense, finding that reports supporting timely denials raised triable issues on the remaining claims.
Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2023 NY Slip Op 50794(U)) Appellate Term, Second DepartmentApplies (b) (3) to hold that the provider's qualified assertion of mailing verification only insofar as proper and in its possession raises no triable issue of compliance or reasonable justification for noncompliance.
Remedy Chiropractic, P.C. v Nationwide Ins. (2022 NY Slip Op 50935(U)) Appellate Term, Second DepartmentApplies (b) (3) to affirm dismissal where the provider's qualified mailing assertion and partial response withholding allegedly objectionable material failed to raise a triable issue of compliance or reasonable justification for noncompliance.
Ocean Diagnostic Imaging, P.C. v Nationwide Mut. Ins. Co. (2006 NY Slip Op 50477(U)) Appellate Term, Second DepartmentHolds, accepting the insurer's argument under (b) (3), that unanswered timely EUO verification requests prevented the period to pay or deny from beginning and made the payment claim premature.
Darlington Med. Diagnostics, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51634(U)) Appellate Term, First DepartmentApplies (b) (3) to dismiss the provider's claim as premature, explaining that the insurer need not pay or deny until requested verification is received and finding its initial and follow-up verification letters timely mailed and received.
Elite Chiropractic Servs., PC v Travelers Ins. Co. (2005 NY Slip Op 51735(U)) Appellate Term, First DepartmentApplies (b) (3) to dismiss the provider's action as premature because the provider and assignor failed to answer timely verification requests, leaving the insurer's time to pay or deny untriggered.
New York Manual, P.T., P.C. v Nationwide Affinity Ins. Co. of Am. (2023 NY Slip Op 50281(U)) Appellate Term, Second DepartmentApplies (b) (3) to affirm dismissal because the provider's assertion that verification was mailed only insofar as proper and in its possession failed to raise a triable issue of compliance or reasonable justification for noncompliance.
Heights Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 52326(U)) Appellate Term, First DepartmentApplies (b) (3) to grant the insurer summary judgment dismissing one claim because the provider's failure to respond to a timely and proper verification request concerning that claim was undisputed.
Triangle R Inc. v Praetorian Ins. Co. (2010 NY Slip Op 52041(U)) Appellate Term, First DepartmentApplies (b) (3) to grant the insurer summary judgment dismissing the claim as premature because it undisputedly never received a response to its verification requests for medical records.
Krishna v Liberty Mut. Ins. Co. (2009 NY Slip Op 51312(U)) Appellate Term, First DepartmentApplies (b) (4) to find that an NF-10 identifying an independent peer review sufficiently states the factual basis for denial; the amplified report raises a triable medical-necessity issue.
Beta Supply, Inc. v Government Employees Insurance Co. (2008 NY Slip Op 51406(U)) Appellate Term, First DepartmentApplies (b) (3) to dismiss the provider's action as premature because verification requests were presumed timely mailed and received and the provider undisputedly failed to respond.
East Coast Med. Care, P.C. v State Farm Mut. Auto Ins.Co. (2008 NY Slip Op 50118(U)) Appellate Term, First DepartmentApplies (b) (4) to hold that denial forms identifying an independent consultant's review sufficiently apprised the provider of the factual basis for denial, requiring denial of the provider's motion to preclude those forms.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 27234) Appellate Term, Second DepartmentRelies on (b) (4) to uphold a medical-necessity denial referring to a negative peer review report without stating supporting facts or medical rationale, and directs that contrary decisions no longer be followed.
Boai Zhong Yi Acupuncture Servs. P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 26485) Appellate Term, Second DepartmentHolds that (b) (4) does not require attaching peer review or IME reports to denials, but its requirement to release reports upon request does not excuse conclusory denials that fail to state the factual basis and medical rationale.
King’s Med. Supply Inc. v Country-Wide Ins. Co. (2004 NY Slip Op 24394) Trial courtRelies on (b) (4) with other authorities to require a detailed factual basis and medical rationale for a medical-necessity denial, finding the insurer's conclusory statement inadequate to defeat the provider's summary judgment motion.
Pro-Align Chiropractic, P.C. v Travelers Prop. Cas. Ins. Co. (2017 NY Slip Op 27415) Trial courtApplies (b) (3) in finding that the insurer omitted the required 120-day warning from its verification demands, while the provider's objection letters reasonably justified noncompliance.
SK Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 26227) Trial courtHolds that (b) (4)'s requirement to disclose reports does not restrict the insurer to calling the original peer reviewer at trial, permitting a substitute expert whose testimony stayed within the original report's facts and opinions.
American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U)) Trial courtApplies (b) (3) to reject the arbitrator's reliance on the absence of a workers' compensation denial as a reason to excuse verification, since verification precedes denial and a denial after 120 days is optional.
Sloan v Nationwide Mut. Ins. Co. (2022 NY Slip Op 50997(U)) Trial courtHolds that the EUO exception in (b) (3) defeats the insurer's argument that outstanding EUO verification made denial premature, because that verification did not bar denial after two nonappearances.
Medalliance Med. Health Servs. v Travelers Prop. Cas. Ins. Co. (2021 NY Slip Op 50737(U)) Trial courtRejects dismissal under (b) (3) because verification requests went to the wrong address, and cites (b) (4) in discussing a peer review report whose conclusions the provider's expert disputed.
Precise Physical Therapy Solutions v State Farm Mut. Auto. Ins. Co. (2020 NY Slip Op 20254) Trial courtHolds that (b) (3) does not specify a 120-day deadline for returning a signed EUO transcript, and rejects dismissal where the insurer supplied no contract imposing that deadline.
Government Employees Ins. Co. v Mayzenberg (2025 NY Slip Op 06527) Court of AppealsCites (b) (3)'s permission to deny reimbursement for incomplete verification as a reason a broader professional-misconduct defense could encourage expansive record demands and settlement pressure.
Matter of Progressive Cas. Ins. Co. (Elite Med. Supply of N.Y., LLC) (2018 NY Slip Op 04122) Appellate Division, Fourth DepartmentRelies on the master arbitrator's interpretation of (b) (3), allowing adjudication of a timely reasonable justification and an opportunity to supply verification if rejected, to uphold review for substantive legal error rather than de novo factual review.
Hernandez v Merchants Mut. Ins. Co. (2022 NY Slip Op 04156) Appellate Division, Second DepartmentRelies on (b) (4) in finding that the insurer failed to produce admissible evidence raising a triable issue on its medical-justification denial, leaving the claimant's summary judgment showing unrebutted.
Freligh v Government Empls. Ins. Co. (2018 NY Slip Op 00584) Appellate Division, Third DepartmentQuotes (b) (3) as ordinarily requiring receipt of all requested relevant information before payment or denial, in addressing whether the claimant's lost-wage proof constituted proper verification.
Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co. (2004 NY Slip Op 24527) Appellate Term, Second DepartmentCites (b) (3) for withholding payment or denial pending requested verification and (b) (1) concerning IME noncompliance, while distinguishing those postclaim remedies from the consequences of nonappearance at a preclaim IME.
Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U)) Appellate Term, Second DepartmentCites (b) (4) with other authorities for precluding the insurer's defenses after its failure to timely pay or deny, in addressing its challenge to the treatment's medical necessity.
Park Slope Med. & Surgical Supply, Inc. v Travelers Ins. Co. (2012 NY Slip Op 22200) Appellate Term, Second DepartmentRelies on (b) (4) to recognize peer-review denials for lack of medical necessity, supporting rejection of the provider's argument that the insurer must independently prove the underlying medical facts before presenting its defense based on submitted records.
A.B. Med. Servs. PLLC v Commercial Mut. Ins. Co. (2006 NY Slip Op 26118) Appellate Term, Second DepartmentCites (b) (4) to recognize that peer reviews need not accompany denial forms, while finding the insurer's medical necessity defense precluded because the denials lacked a sufficiently particular factual basis and medical rationale.
A-Quality Med. Supply v GEICO Gen. Ins. Co. (2013 NY Slip Op 23088) Appellate Term, Second DepartmentRelies on (b) (4)'s requirement to supply a copy of a peer review report on written demand, and the absence of any prescribed report format, to reject treating undated, unsigned or unnotarized reports as invalid bases for denials.
East Acupuncture, P.C. v Allstate Ins. Co. (2007 NY Slip Op 27109) Appellate Term, Second DepartmentCites (b) as an example of context determining whether "applicant" includes provider assignees, noting that (b) (2) uses the term for the injured person in one clause and also for assignees in another.
A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co. (2005 NY Slip Op 51902(U)) Appellate Term, Second DepartmentCites (b) (4) to explain that a peer review report need not accompany the denial, but holds the medical-necessity defense precluded because the denial lacked a sufficiently particular factual basis and medical rationale.
Island Life Chiropractic Pain Care, PLLC v 21st Century Ins. Co. (2021 NY Slip Op 21340) Appellate Term, Second DepartmentDistinguishes (b) (3)'s written-verification defense, which applies only to claims for which verification was specifically requested, from EUO and IME nonappearance defenses that may support timely denials of subsequently submitted claims.
A.B. Med. Servs. PLLC v GEICO Cas. Ins. Co. (2006 NY Slip Op 26133) Appellate Term, Second DepartmentNotes that (b) (4) does not require attaching peer reviews to denial forms, but holds the insurer's vague denials insufficient to preserve the medical necessity defense because they lacked a particular factual basis and medical rationale.
Summit Psychological, P.C. v General Assur. Co. (2005 NY Slip Op 25263) Appellate Term, Second DepartmentRelies on (b) (3)'s prohibition on denial before requested verification is received to explain that proper proof of claim is an essential predicate for denial, invalidating the insurer's preclaim blanket denials.
Olympic Chiropractic, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50011(U)) Appellate Term, Second DepartmentRelies on (b) (4) to explain that a peer review report need not accompany a denial, but the denial must state the factual basis and medical rationale or the report must be supplied within the denial period.
Shtarkman v Allstate Ins. Co. (2005 NYSlipOp 51028(U)) Appellate Term, Second DepartmentRelies on (b) (3)'s prohibition against denial before receipt of requested verification as additional support for holding that a blanket denial issued before receipt of the provider's claim was invalid.
Island Life Chiropractic Pain Care, PLLC v Zipcar (2021 NY Slip Op 50844(U)) Appellate Term, Second DepartmentRejects, under (b) (3), the provider's premise that an insurer must issue a denial for failure to supply requested verification, as one basis for denying the motion to strike defenses.
Careplus Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 28341) Appellate Term, Second DepartmentCites (b) (4) in describing appellate authority that a peer-review denial need not detail its factual basis or medical rationale because the provider may request the report underlying the medical-necessity defense.
A.B. Med. Servs. PLLC v Clarendon Natl. Ins. Co. (2006 NY Slip Op 51415(U)) Appellate Term, Second DepartmentRejects the argument that failure to supply a peer review report within 30 days itself precludes a medical-necessity defense, reasoning that (b) (4) permits requesting the report but provides no sanction for failing to supply it.
Ocean Diagnostic Imaging P.C. v Lumbermens Mut. Cas. Co. (2005 NY Slip Op 50743(U)) Appellate Term, Second DepartmentCites (b) (3)'s allowance to await requested verification, but explains that failure to exhaust follow-up requirements independently rendered the IME nonappearance denials without merit, even if mailing proof had sufficed.
Omega Diagnostic Imaging, P.C. v MVAIC (2011 NY Slip Op 51259(U)) Appellate Term, First DepartmentRelies on (b) (3)'s prohibition against denial before requested verification is received to support finding that the claim accrued for limitations purposes upon denial after the provider responded, rather than 30 days after initial claim receipt.
New Millenium Med. Supply v Clarendon Natl. Ins. Co. (2010 NY Slip Op51820(U)) Appellate Term, First DepartmentDistinguishes a general denial terminating benefits for lack of continuing disability under (b) (2) from a specific submitted claim, rejecting the provider's reliance on the former situation to determine accrual of its action.
Expo Med. Supplies, Inc. v St. Paul Fire & Mar. Ins. Co. (2006 NY Slip Op 52251(U)) Appellate Term, Second DepartmentCites (b) (4) to explain that a peer review need not accompany a denial, while requiring a specific factual basis and medical rationale in the denial or delivery of the report within 30 days, absent tolling.
Dilon Med. Supply Corp. v Travelers Ins. Co. (2005 NY Slip Op 25113) Trial courtCites (b) (3) for the prohibition, subject to exceptions inapplicable here, on issuing a denial while verification remains outstanding, in addressing the insurer's response to unanswered requests for medical-necessity verification.
A.T. Med., P.C. v State Farm Mut. Ins. Co. (2005 NY Slip Op 25461) Trial courtApplies (b) (3) to find a denial issued before requested verification was supplied improper, supporting the provider's prima facie showing despite the insurer's separate licensing defense.
HKP Physical Therapy, P.C. v Government Empls. Ins. Co. (2019 NY Slip Op 29381) Trial courtExplains that (b) (3) permits denial after more than 120 days without requested verification or written reasonable justification, pairing the insurer's duty to show good cause for its requests with the provider's duty to justify refusal.
Millennium Radiology, P.C. v New York Cent. Mut. Fire Ins. Co.(2009 NY Slip Op 50877(U)) Trial courtCites (b) (4) to explain that a denial based on an IME or peer review need not state the medical rationale, provided the insurer supplies the report upon written request, in addressing the insurer's medical-necessity defense.
Apazidis, M.D., P.C. v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op 50498(U)) Trial courtRelies on (b) (3)'s requirement that verification requests warn the applicant of possible denial for noncompliance within 120 days when examining the insurer's denial for outstanding documentary verification.
DWP Pain Free Med. P.C. v Progressive Northeastern Ins. Co. (2006 NY Slip Op 26531) Trial courtCites (b) (3) for the prohibition on issuing a denial while verification remains outstanding, in considering the effect of the provider's response to a demand for signature verification.
Baldwin Med. Servs., P.C. v Maya Assur. Co (2026 NY Slip Op 51329(U)) Trial courtCites (b) (3)'s prohibition on denial before requested verification is received in explaining the verification process, while denying summary judgment because the insurer failed to establish proper mailing of its initial request.
Titan Diagnostic Imaging Servs. Inc. v State Farm Mut. Auto Ins. Co (2024 NY Slip Op 24209) Trial courtCites (b) (3) for withholding payment or denial until demanded verification is supplied, as part of its reasoning on the insurer's defense that the provider failed to comply with verification requests within 120 days.
MVAIC v Stand-Up MRI of Manhattan, P.C. (2011 NY Slip Op 51187(U)) Trial courtCites (b) (3) as prohibiting denial while verification remains outstanding, but explains that a response supplying only some requested material requires the insurer to act rather than simply treat verification as still outstanding.
A.B. Med. Servs. PLLC v GEICO Gen. Ins. Co. (2008 NY Slip Op 52641(U)) Trial courtCites (b) (3) for the rule that the insurer need not pay or deny until all relevant requested verification is received, supporting its conclusion that no denial was required while verification remained outstanding.
SZ Med. P.C. v Clarendon Natl. Ins. Co. (2006 NY Slip Op 51428(U)) Appellate Term, Second DepartmentCites (b) (4) in a concurrence to argue that a peer review report need be released only upon written request, opposing a requirement to supply the report within the 30-day denial period.
AOM Med. Supply, Inc. v Hereford Ins. Co. (2020 NY Slip Op 51366(U)) Appellate Term, Second DepartmentNotes the insurer's reliance on (b) (3) to deny claims for verification outstanding beyond 120 days, and affirms dismissal without prejudice after finding prima facie proof of nonreceipt.
St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. (2009 NY Slip Op 29508) Appellate Term, Second DepartmentNotes that the dissent cites (b) (3) for the proposition that a claim remains incomplete until verification is supplied, reasoning that a follow-up request merely reminds the provider of an outstanding demand.
Accessible & Advance Med. P.C. v Allstate Ins. Co. (2006 NY Slip Op 51599(U)) Appellate Term, Second DepartmentCites (b) (4) in a concurrence to argue that a peer review report need be released only upon written request, opposing a requirement to supply the report within the 30-day denial period.
A.M. Med. Servs., P.C. v Allstate Ins. Co. (2006 NY Slip Op 51426(U)) Appellate Term, Second DepartmentCites (b) (4) in a concurrence to argue that a peer review report need be released only upon written request, opposing a requirement to supply the report within the 30-day denial period.
A.I.D. Med. Supplies v GEICO Gen. Ins. Co. (2007 NY Slip Op 51044(U)) Appellate Term, First DepartmentQuotes another decision's reliance on (b) (4)'s report-release requirement to explain why a peer-review denial need not state the medical rationale, after finding that the insurer raised a triable medical-necessity issue.
Behavioral Diagnostics v Allstate Ins. Co. (2004 NY Slip Op 24041) Trial courtCites (b) (4) in describing the insurer's medical-necessity denials of psychological testing, record evaluation, and interpretation services, with denial timeliness stipulated and medical necessity left as the sole trial issue.
Acuhealth Acupuncture, P.C. v New York City Tr. Auth. (2016 NY Slip Op 50297(U)) Trial courtQuotes another decision's discussion of (b) (3)'s prohibition against denying a claim before requested verification is received, subject to exceptions, as background to payment priority and arbitral authority to award beyond policy limits.
Jiang Acupuncture PC v State Farm Ins. Co. (2023 NY Slip Op 50961(U)) Trial courtNotes the insurer's reliance on (b) (3) in seeking summary judgment based on the provider's failure to supply additional documentary verification within 120 days.
Sabodash v Hereford Ins. Co. (2021 NY Slip Op 51099(U)) Trial courtQuotes (b) (3) in explaining that, after more than 120 days, an insurer may deny for missing verification within the applicant's control or possession if the request gave the required warning and no reasonable justification was supplied.
Alsaad Med., P.C. v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op50532(U)) Trial courtQuotes (b) (3) for permission to deny when verification remains outstanding beyond 120 days without reasonable written justification, provided the request warned of that consequence, in a discussion of summary judgment for unanswered verification.
Tian Shan Acupuncture PC v Global Liberty Ins. Co. (2019 NY Slip Op 50728(U)) Trial courtQuotes (b) (3) as permitting denial after more than 120 days without requested verification or a reasonable justification, provided the request warned of that consequence, in outlining the verification rules before addressing IME nonappearance.
Pro-Align Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50341(U)) Trial courtQuotes (b) (3) in a general discussion of verification, explaining that an unanswered demand permits denial after 120 days if the applicant supplies neither the requested material nor reasonable justification and received the required warning.
Global Liberty Ins. Co. v Jonathan Lewin, M.D., P.C. (2017 NY Slip Op 50897(U)) Trial courtQuotes another decision citing (b) (3) for the proposition that an additional verification request within 15 business days creates an exception to the 30-day payment-or-denial deadline.
Odessa Med. Supply, Inc. (b) v Government Employees Ins. Co. (2007 NY Slip Op 27542) Trial courtQuotes another decision's reasoning that (b) (4) requires release of a medical examination or peer review report upon written request, rather than inclusion of the medical rationale in the denial form, as grounds for renewal.
Elmont Open MRI & Diagnostic Radiology, P.C. v Country Wide Ins. Co. (2004 NY Slip Op 50946(U)) Trial courtQuotes another decision's reading of (b) (4) as permitting a medical-necessity defense based on peer review or a medical examination, in rejecting reliance on a nurse's medical opinion.

Subdivision (c) (198 decisions)

Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067) Court of AppealsApplies (c) to the insurer's failure to pay or deny within 30 days, supporting preclusion of its assignment-validity defense where it also failed to request verification of forms stating that the signature was on file.
Westchester Med. Ctr. v Nationwide Mut. Ins. Co. (2010 NY Slip Op 08933) Appellate Division, Second DepartmentApplies (c) to reject the provider's prima facie entitlement to summary judgment because the insurer made a partial payment and partial denial within 30 days after receiving the claim.
Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC (2011 NY Slip Op 01948) Appellate Division, First DepartmentHolds that (c) does not preclude retroactive denial for IME nonappearances, which breach a condition precedent to coverage, regardless of denial timeliness or the insurer's initial reliance on lack of medical necessity.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430) Appellate Division, Second DepartmentRelies on (c) to hold that an insurer failing to timely deny or request verification cannot challenge the billing forms' contents under the business records exception, although it may challenge proof of mailing, receipt or failure to pay or deny.
Nyack Hosp. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 07663) Appellate Division, Second DepartmentHolds that a timely but fatally defective denial cannot be cured by supplying omitted basic claim information after (c)'s 30-day period expires, warranting preclusion and summary judgment for the provider.
American Tr. Ins. Co. v Lucas (2013 NY Slip Op 07273) Appellate Division, First DepartmentHolds that (c)'s denial deadline does not bar retroactive denial after assignors fail to attend duly scheduled IMEs, because that failure voids the policy from inception, warranting declarations of no coverage.
New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. (2006 NY Slip Op 06223) Appellate Division, Second DepartmentHolds that the insurers' timely partial-denial letter did not avoid preclusion under (c) (1) because they failed to establish issuance in duplicate and departmental approval, despite adequately stating the denial ground and required claim information.
Westchester Med. Ctr. v Hereford Ins. Co. (2012 NY Slip Op 04156) Appellate Division, Second DepartmentApplies (c) to find the provider entitled to summary judgment where its bill was mailed and received, the insurer failed to pay or deny within 30 days, and the insurer raised no triable issue in opposition.

Show all 198 decisions

Mercury Cas. Co. v Encare, Inc. (2011 NY Slip Op 08969) Appellate Division, First DepartmentApplies (c) to uphold dismissal of the insurer's complaint because an untimely or otherwise defective denial precludes a claim challenge, rejecting the insurer's attempt to invoke the narrow lack-of-coverage exception.
Mount Sinai Hosp. v Allstate Ins. Co. (2006 NY Slip Op 00490) Appellate Division, Second DepartmentApplies (c) to find prima facie proof that the insurer failed to pay or deny within 30 days, but denies the provider summary judgment because verification compliance remained a triable issue.
Wyckoff Hgts. Med. Ctr. v Government Empls. Ins. Co. (2014 NY Slip Op 01166) Appellate Division, Second DepartmentApplies (c) in finding a factual issue about timely and proper denial despite incorrect claim and disputed amounts, which were minor errors under the circumstances, requiring denial of the provider's summary judgment motion.
Lenox Hill Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 08330) Appellate Division, Second DepartmentHolds under (c) that, where the provider seeks summary judgment solely for failure to pay or deny within 30 days, evidence of a timely denial raises the necessary triable issue and defeats the motion.
Hernandez v Merchants Mut. Ins. Co. (2022 NY Slip Op 04156) Appellate Division, Second DepartmentApplies (c) to find the claimant's prima facie entitlement to summary judgment established by proof that statutory billing forms were mailed and received and that the insurer failed to pay or validly deny within 30 days.
Hospital for Joint Diseases v New York City Tr. Auth. (2005 NY Slip Op 01679) Appellate Division, Second DepartmentApplies (c) to assess timely denial, holding that the self-insurer's evidence raised a factual issue sufficient to defeat the provider's summary judgment motion but insufficient to support its own cross motion.
New York Hosp. Med. Ctr. of Queens v Allstate Ins. Co. (2014 NY Slip Op 00640) Appellate Division, Second DepartmentApplies (c) to uphold provider summary judgment based on a postal receipt and the sender's affidavit showing receipt and failure to pay or properly deny within 30 days, with no factual issue concerning timely payment, denial, or verification requests.
Westchester Med. Ctr. v Government Empls. Ins. Co. (2014 NY Slip Op 00500) Appellate Division, Second DepartmentApplies (c) to grant the provider summary judgment for failure to pay or deny within 30 days, declining to consider the insurer's absence-of-coverage argument because it was first raised on appeal.
New York Univ Hosp. Tisch Inst. v New York City Tr. Auth. (2004 NY Slip Op 01159) Appellate Division, Second DepartmentApplies (c) to preclude the insurer from disclaiming coverage after it failed to reject the provider's claim within 30 days, granting the provider summary judgment on that claim.
Oleg Barshay, D.C., P.C. v State Farm Ins. Co. (2006 NY Slip Op 26496) Appellate Term, Second DepartmentApplies (c) to find the denial untimely because the insurer failed to establish tolling through a proper and timely verification request.
Careplus Med. Supply Inc. v State-Wide Ins. Co. (2005 NY Slip Op 25545) Appellate Term, Second DepartmentApplies (c) to find the denial untimely based on the same completed denial form submitted by both parties, which established claim receipt, while treating earlier incomplete denial forms as ineffective.
S & M Supply Inc. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 50693(U)) Appellate Term, Second DepartmentApplies (c) to find the denials issued well beyond the 30-day payment-or-denial period, with the insurer's EUO requests failing to toll that period.
Careplus Med. Supply Inc. v Travelers Home & Mar. Ins. Co. (2005 NYSlipOp 50648(U)) Appellate Term, Second DepartmentApplies (c) to preclude the insurer's defenses after its conceded failure to pay or deny within 30 days, where it failed to establish verification requests that tolled the deadline.
A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co. (2005 NY Slip Op 51902(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses to a claim the insurer concededly failed to pay or deny within 30 days, supporting partial summary judgment for the provider.
Ultra Diagnostics Imaging v Liberty Mut. Ins. Co. (2005 NY Slip Op 25402) Appellate Term, Second DepartmentApplies (c) to preclude fee-schedule and excessive-billing defenses where the denial forms showed denials beyond 30 days, and rejects the insurer's contention that its fraud defense escaped that preclusion.
A.B. Med. Servs. PLLC v USAA Gen. Indem. Co. (2005 NY Slip Op 25297) Appellate Term, Second DepartmentApplies (c) to preclude the IME nonattendance defense for claims the insurer neither timely denied nor subjected to timely verification requests, supporting summary judgment for the providers on those claims.
A.B. Med. Servs. v GEICO Ins. (2003 NY Slip Op 23949) Appellate Term, Second DepartmentApplies (c) to hold that failure to timely mail or otherwise deliver a claim determination within 30 days waived nearly all objections and defenses concerning the adequacy or propriety of the provider's claim.
Delta Diagnostic Radiology, P.C. v Republic W. Ins. Co. (2007 NY Slip Op 27088) Appellate Term, Second DepartmentApplies (c) to find that facially timely denials did not establish timely denial without proof of actual mailing or an office practice supporting a mailing presumption, resulting in summary judgment for the provider.
PDG Psychological P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50246(U)) Appellate Term, Second DepartmentApplies (c) to preclude the insurer's defenses because it failed to establish mailing of the denial forms within the 30-day determination period, with dates of claim receipt established by forms annexed to the insurer's motion.
VS Care Acupuncture v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50164(U)) Appellate Term, First DepartmentApplies (c) to find a denial mailed on Monday timely because the last day of the 30-calendar-day payment or denial period fell on Saturday.
Prestige Med. & Surgical Supply, Inc. v Clarendon Natl. Ins. Co. (2006 NY Slip Op 51672(U)) Appellate Term, Second DepartmentApplies (c) to preclude the insurer's defenses because adjusters' assertions of timely denial, without personal knowledge of mailing or facts supporting a mailing presumption, failed to establish denial within 30 days of claim receipt.
S&M Supply Inc. v Progressive Ins. Co. (2005 NYSlipOp 51312(U)) Appellate Term, Second DepartmentApplies (c)'s 30-day deadline to a claim for which the insurer failed to prove proper mailing of verification requests, leaving its late denial without an established toll.
Triboro Chiropractic & Acupuncture P.L.L.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50856(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses to three claims not paid or denied within 30 days, awarding partial summary judgment while leaving timely denied fee-schedule claims for further proceedings.
A.B. Med. Servs. PLLC v USAA Cas. Ins. Co. (2004 NY Slip Op 51682(U)) Appellate Term, Second DepartmentApplies (c) to grant summary judgment on a claim where the billing manager's personal-mailing affidavit established presumed receipt, counsel's denial did not rebut it, and the insurer failed to pay or deny within 30 days.
Alur Med. Supply, Inc. v Progressive Ins. Co. (2008 NY Slip Op 52191(U)) Appellate Term, Second DepartmentHolds that (c)'s 30-day period was not tolled by a purported verification letter that neither demanded nor required a response, making the denial untimely and precluding the insurer's medical-necessity defense.
Devonshire Surgical Facility v GEICO (2007 NY Slip Op 51308(U)) Appellate Term, First DepartmentApplies (c) to preclude a fraudulent-billing defense because the insurer failed to deny the provider's claims within 30 days, affirming summary judgment for that provider.
Star Med. Servs., P.C. v Allstate Ins. Co. (2006 NYSlipOp 50344(U)) Appellate Term, Second DepartmentHolds that sending an EUO demand to the assignor's attorney did not cure failure to send it to the assignor's proper address or toll the 30-day period under (c), precluding most defenses while preserving the covered-accident defense.
Careplus Med. Supply Inc. v General Assur. Co. (2005 NY Slip Op 50429(U)) Appellate Term, Second DepartmentApplies (c) to preclude the IME nonattendance defense for one untimely denied claim, while separately examining proof of IME notice mailing for the timely denied claims.
PDG Psychological, P.C. v Lumbermans Mut. Cas. Co. (2007 NY Slip Op 51343(U)) Appellate Term, Second DepartmentApplies (c) to preclude the medical-necessity defense because the insurer's affidavit established neither actual mailing nor office procedures ensuring proper addressing and mailing of its denial, and grants the provider summary judgment.
Englinton Med., P.C. v MVAIC (2007 NY Slip Op 50164(U)) Appellate Term, Second DepartmentHolds that (c)'s 30-day deadline runs from receipt of claim forms even before the insurer determines whether the assignor is a qualified person, and rejects a denial letter lacking the prescribed or approved format under (c) (1).
M.G.M. Psychiatry Care P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 51286(U)) Appellate Term, Second DepartmentApplies (c)'s 30-day deadline to find the denials untimely where the insurer failed to prove mailing of a request that the assignor sign and return an EUO transcript.
Rigid Med. of Flatbush, P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50582(U)) Appellate Term, Second DepartmentApplies (c) in finding that the denial form showed the claim was denied more than 30 days after receipt, despite the insurer's assertion of a timely denial based on EUO nonappearance.
Medwide Med. Supply Inc. v Country-Wide Ins. Co. (2005 NYSlipOp 51078(U)) Appellate Term, Second DepartmentApplies (c) to hold that an untimely denial precluded defenses to one claim, with no relevant exception, and warranted summary judgment for the provider on that ground alone.
Shtarkman v Allstate Ins. Co. (2005 NYSlipOp 51028(U)) Appellate Term, Second DepartmentApplies (c) to reject a blanket denial issued before receipt of the provider's claim and preclude the intoxication defense because the insurer neither paid nor denied within 30 days and did not request verification.
King’s Med. Supply Inc. v Allstate Ins. Co. (2005 NYSlipOp 50451(U)) Appellate Term, Second DepartmentApplies (c) to preclude the insurer's defenses to a claim neither paid nor denied within 30 days, requiring summary judgment for the provider on that claim.
A.B. Med. Servs. PLLC v Country-Wide Ins. Co. (2005 NY Slip Op 50255(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses to 55 claims, explaining that an investigation-delay letter identifying neither the verification sought nor its source does not toll the 30-day deadline.
A.b. Med. Servs. Pllc v Cna Ins. Co. (2004 NY Slip Op 50061(U)) Appellate Term, First DepartmentHolds that failure to pay or deny within (c)'s 30-day period waived defenses concerning missing claim-form signatures and medical necessity, entitling the provider to summary judgment on its neurological-testing claim.
Sheepshead Bay Med. Supply, Inc. v Erie Ins. Co. of N.Y. (2021 NY Slip Op 50491(U)) Appellate Term, Second DepartmentApplies (c) (1) to reject a challenge to outdated denial forms because they contained substantially the same pertinent information as the prescribed form, also finding that the insurer established mailing in duplicate.
Excel Imaging, P.C. v MVAIC (2010 NY Slip Op 50998(U)) Appellate Term, Second DepartmentApplies (c) (1) to deny the insurer summary judgment because factual issues remained over whether its denial was issued in duplicate, after quoting another decision applying that requirement.
East Coast Acupuncture, P.C. v New York Cent. Mut. Ins. (2008 NY Slip Op 50344(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses to one claim because the insurer failed to pay or deny within 30 days and failed to establish an extension through timely verification requests.
Response Med. Equip. v General Assur. Co. (2006 NY Slip Op 51765(U)) Appellate Term, First DepartmentApplies (c) to preclude the insurer's medical-necessity defense on a claim concededly not denied within 30 days of receipt, entitling the provider to summary judgment on that claim.
Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2006 NY Slip Op 51047(U)) Appellate Term, Second DepartmentHolds that an explanation of benefits cannot substitute for the prescribed denial form under (c) (1), precluding the insurer's defenses to the claim for which the record contained no required denial form.
Health E. Ambulatory Surgical Ctr. v Country-Wide Ins. Co. (2024 NY Slip Op 51346(U)) Appellate Term, First DepartmentApplies (c) to find that the provider failed to prove its claim overdue because the insurer's admissions also established timely, unanswered verification requests, requiring dismissal of the complaint.
Clear Water Psychological Servs., P.C. v Mid-Century Ins. Co. (2022 NY Slip Op 50621(U)) Appellate Term, Second DepartmentApplies (c) to find a factual issue about timely denial where the insurer denied more than 30 days after the second scheduled EUO but failed to prove the first EUO had been mutually rescheduled, preventing summary judgment on EUO nonappearance.
Great Wall Acupuncture, P.C. v New York Central Mutual Insurance Company (2009 NY Slip Op 50224(U)) Appellate Term, Second DepartmentHolds that an untimely EUO request did not toll the insurer's pay-or-deny period under (c), precluding the defense based on the provider owner's failure to appear and affirming judgment for the provider.
Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2007 NY Slip Op 52453(U)) Appellate Term, Second DepartmentApplies (c) to the insurer's admission that its denial exceeded the 30-day claim-determination period, awarding the provider summary judgment for statutory interest and attorney fees despite deficient business-record proof because the insurer admitted receipt and paid after suit began.
PDG Psychological P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 51432(U)) Appellate Term, Second DepartmentApplies (c) to find timely denial unproved because the claims representative's affidavit showed neither actual mailing through personal knowledge nor a sufficiently detailed standard office mailing procedure.
Vista Surgical Supplies, Inc. v State Farm Mut. Ins. Co. (2006 NY Slip Op 51189(U)) Appellate Term, Second DepartmentHolds that denials issued more than 30 days after receipt of final verification violate (c), precluding the insurer's medical necessity defense and warranting partial summary judgment for the provider.
Elite Psychological Servs., P.C. v Trumbull Ins. Co. (2005 NY Slip Op 51427(U)) Appellate Term, First DepartmentHolds that the insurer could not toll (c)'s 30-day period without proving the policy contained an endorsement authorizing EUOs, rendering its denial based on the assignor's nonattendance untimely.
Damadian Mri In Garden City v Liberty Mut. Ins. Co. (2003 NY Slip Op 51702(U)) Appellate Term, Second DepartmentApplies (c) to preclude the insurer's medical-necessity defense after its failure to deny within 30 days of receipt, affirming summary judgment for the provider.
Bronx Community Med., P.C. v MVAIC (2024 NY Slip Op 51538(U)) Appellate Term, Second DepartmentApplies (c) to hold that the insurer's time to pay or deny never began because claim receipt was not established, requiring dismissal without prejudice as premature.
T & M Rehab PT, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52407(U)) Appellate Term, Second DepartmentRelies on (c) (1)'s existing duplicate-denial requirement to reject the provider's assertion of a change in law and affirm denial of its motion to renew summary judgment.
Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52406(U)) Appellate Term, Second DepartmentRejects the challenge under (c) (1) to duplicate issuance where denials were mailed to the provider, assignor and assignor's attorney, and the provider offered no argument why those mailings failed to satisfy the requirement.
Boro Med. Supplies, Inc. v Country Wide Ins. Co. (2008 NY Slip Op 52698(U)) Appellate Term, Second DepartmentApplies (c) to find that an unsigned affidavit failed to prove denial within 30 days, precluding the insurer's defense that the provider submitted its claim more than 45 days after service and entitling the provider to summary judgment.
Health Plus Med., P.C. v American Mfrs. Mut. Ins. Co. (2008 NY Slip Op 51444(U)) Appellate Term, Second DepartmentApplies (c) to deny the insurers summary judgment because their examiner's affidavit failed to establish timely mailing of verification requests and denials, leaving them unable to show that their medical-necessity defense was not precluded.
Delta Diagnostic Radiology, P.C. v Farmers New Century Ins. Co. (2007 NY Slip Op 52284(U)) Appellate Term, Second DepartmentApplies (c) to preclude medical-necessity and excessive-fee defenses because the insurer failed to prove timely mailing of its denials through personal mailing knowledge or an office practice ensuring proper addressing and mailing, affirming summary judgment for the provider.
Inwood Hill Med. P.C. v Utica Mut. Ins. Co. (2007 NY Slip Op 51309(U)) Appellate Term, First DepartmentApplies (c) to hold that the insurer's undisputed failure to deny within 30 days precluded statutory defenses, defenses based on policy conditions or exclusions, and fraudulent-billing defenses, granting summary judgment to the providers.
GMV Med. Supplies, Inc. v MVAIC (2007 NY Slip Op 50601(U)) Appellate Term, Second DepartmentRejects the insurer's contention that the assignor's qualified-person status must first be established, holding that (c)'s 30-day pay-or-deny period begins upon receipt of the claim form without awaiting a qualification determination.
Delta Diagnostic Radiology, P.C. v Allstate Ins. Co. (2006 NY Slip Op 52034(U)) Appellate Term, Second DepartmentApplies (c) to preclude the medical-necessity defense because the insurer failed to establish timely mailing of its denial, requiring summary judgment for the provider.
Fair Price Med. Supply Corp. v Liberty Mut. Ins. Co. (2006 NY Slip Op 51438(U)) Appellate Term, Second DepartmentApplies (c) to preclude an excessive-charge defense because a denial dated within 30 days after verification did not establish timely mailing without personal knowledge or a sufficiently detailed office mailing procedure.
Dilon Med. Supply Corp. v Progressive Cas. Ins. Co. (2006 NY Slip Op 50908(U)) Appellate Term, Second DepartmentApplies (c) to find one denial untimely, explaining that EUO requests did not toll the 30-day determination period because the insurer failed to show a policy endorsement authorizing EUOs.
Star Med. Servs. P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50505(U)) Appellate Term, Second DepartmentHolds that EUO requests did not toll the 30-day period under (c) because the insurer failed to prove an authorizing policy endorsement, rendering the denial untimely while leaving the staged accident defense available.
Careplus Med. Supply Inc. v Allstate Ins. Co. (2005 NYSlipOp 51526(U)) Appellate Term, Second DepartmentApplies (c) to preclude the defenses in the denial forms for three claims because the insurer neither paid nor denied within 30 days and failed to prove that the deadline was tolled.
Elmont Open MRI & Diagnostic Radiology, P.C. v Country-Wide Ins. Co. (2007 NY Slip Op 27072) Trial courtApplies (c) and (c) (1) to require a valid denial on the prescribed form within 30 days, granting the provider summary judgment despite the insurer's timely denial.
Liberty Mut. Ins. Co. v Brutus (2022 NY Slip Op 50799(U)) Trial courtApplies (c) to hold that material-misrepresentation denials are subject to the 30-day deadline, granting the provider summary judgment only on the bill that the insurer failed to timely deny.
Tyorkin v Garrison Prop. & Cas. Ins. Co. (2016 NY Slip Op 50846(U)) Trial courtApplies (c) (1) to preclude the insurer's peer review defense because it issued only a reimbursement explanation, without showing either an NF-10 denial or departmental approval of the alternative form.
AR Med. Rehabilitation, P.C. v State-Wide Ins. Co. (2015 NY Slip Op 50631(U)) Trial courtApplies (c) to award judgment to the provider where the insurer failed to pay or deny within 30 days, its investigation delay letters did not request verification or toll the deadline, and it proved no fraud defense.
Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co. (2008 NY Slip Op 50113(U)) Trial courtHolds that (c) (1) permits approved modified denial forms or letters only for partial denials of a provider's bill, so even departmental approval could not validate the insurer's use of a modified form to deny the entire claim.
New York Craniofacial Care, P.C. v Allstate Ins. Co. (2006 NY Slip Op 50500(U)) Trial courtApplies (c) to require the provider's moving papers to show that claims were neither paid nor validly denied within 30 days, finding its affidavit's silence about denials insufficient for summary judgment.
A.B. Med. Servs. PLLC v Farm Family Cas. Ins. Co. (2004 NY Slip Op 24346) Trial courtApplies (c)'s 30-day payment-or-denial deadline in assessing the provider's prima facie entitlement to summary judgment, noting that three medical-necessity denials were dated more than 30 days after receipt of complete proofs of claim.
Liberty Mut. Ins. Co. v Anderson (2023 NY Slip Op 50746(U)) Trial courtApplies (c)'s 30-day deadline to the insurer's material-misrepresentation denials, denying default judgment because the insurer failed to establish timely denials.
Parisien v Avis Budget Car Rental, LLC (2022 NY Slip Op 50883(U)) Trial courtApplies (c) in rejecting the insurer's partial-payment defense because its check did not establish timely payment, in addition to defects in admissibility and proof connecting the check to the claim.
SB Chiropractic, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50316(U)) Trial courtApplies (c)'s 30-day deadline in finding the insurer's partial denials timely, with the claims associate's affidavit establishing mailing and allowing consideration of the insurer's fee-schedule and medical-necessity defenses.
Medalliance Med. Health Servs. v Travelers Prop. Cas. Ins. Co. (2021 NY Slip Op 50737(U)) Trial courtApplies (c) to award the provider summary judgment on claims whose receipt was established by mailing proofs because the insurer failed to show payment, denial, or proper verification requests within the applicable deadlines.
Parisien v Travelers Ins. Co. (2021 NY Slip Op 50396(U)) Trial courtRejects the argument that failure to send denial forms in duplicate under (c) (1) is, by itself, fatal, and notes that the insurer's witnesses also attested to mailing them in duplicate.
Restorative Chiropractic Solutions, PC v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op 50209(U)) Trial courtApplies (c)'s 30-day deadline, measured from receipt of proof of claim including requested verification, in finding that some claims were timely denied after partial payment.
Alleviation Med. Servs., PC v Hertz Co. (2015 NY Slip Op 25285) Trial courtApplies (c) to find a denial issued more than 30 days after the last missed IME untimely, using the denial annexed to the insurer's interrogatory response as evidence supporting the provider's prima facie case.
Corona Comprehensive Med. Care, P.C. v Global Liberty Ins. Co. of N.Y. (2009 NY Slip Op 51432(U)) Trial courtApplies (c)'s 30-day deadline to the workers' compensation defense, treating it as a statutory offset subject to preclusion and finding that the insurer failed to submit admissible proof that its denial was mailed.
Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 08038) Appellate Division, Second DepartmentCites (c)'s 30-day payment-or-denial rule and explains that an additional-information request made within 15 business days of claim receipt may extend that period.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 05602) Appellate Division, Second DepartmentCites (c)'s 30-day payment-or-denial deadline as subject to extension when the insurer requests additional information within 15 business days of receiving the claim.
A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636) Appellate Division, Second DepartmentRelies on (c) to recognize the provider's prima facie showing through proof of mailing and receipt of billing forms and overdue payment, while denying summary judgment because the insurer raised a triable medical-justification issue.
Infinity Health Prods., Ltd. v Eveready Ins. Co. (2009 NY Slip Op 08585) Appellate Division, Second DepartmentCites (c)'s 30-day payment-or-denial rule and explains that timely verification demands extend that period, noting that the insurer's initial demand was timely while reviewing the provider's challenge to a follow-up sent three days early.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 02390) Appellate Division, Second DepartmentCites (c) for the rule that failure to deny or seek verification within 30 days of receiving proof of claim waives defenses other than complete absence of coverage.
Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979) Appellate Division, Second DepartmentNotes under (c) that the insurer did not pay or deny within 30 days of the initial demand, but rejects treating benefits as overdue because timely verification requests tolled the period.
St. Barnabas Hosp. v Allstate Ins. Co. (2009 NY Slip Op 07824) Appellate Division, Second DepartmentApplies (c) to recognize that the insurer denied within 30 days of receiving the completed hospital facility form, but explains that timely issuance did not prevent preclusion because the denial misstated the claim amount and gave an invalid reason.
New York & Presbyt. Hosp. v American Tr. Ins. Co. (2007 NY Slip Op 09376) Appellate Division, Second DepartmentRelies on (c) in finding that proof of mailing and receipt of billing forms and overdue payment established the provider's prima facie case, while the insurer raised a triable issue as to whether benefits were overdue.
Westchester Med. Ctr. v Allstate Ins. Co. (2007 NY Slip Op 08447) Appellate Division, Second DepartmentRelies on (c) (1) in finding the denial timely; because the provider did not establish that the denial was vague or deficient, it failed to show prima facie entitlement to summary judgment.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U)) Appellate Term, Second DepartmentNotes that the medical-necessity denial was timely under (c), but holds it ineffective because it lacked a detailed factual basis and medical rationale and the insurer supplied no other timely basis for denial.
Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U)) Appellate Term, Second DepartmentApplies (c) to the insurer's failure to state any other basis for denial within 30 days of receipt, supporting preclusion despite its subsequent challenge to medical necessity.
A.B. Med. Servs. PLLC v Utica Mut. Ins. Co. (2006 NY Slip Op 26068) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after rejecting timely denial for lack of an affidavit proving mailing through personal knowledge or describing office procedures sufficiently to create a mailing presumption.
A.B. Med. Servs. PLLC v Commercial Mut. Ins. Co. (2006 NY Slip Op 26118) Appellate Term, Second DepartmentApplies (c) to preclude most defenses to claims for which the record contained no denial forms, finding that the insurer failed to pay or deny those claims within 30 days.
East Acupuncture, P.C. v Allstate Ins. Co. (2007 NY Slip Op 27109) Appellate Term, Second DepartmentCites (c) to distinguish the obligation to pay or deny within 30 days from the nonpayment that makes benefits overdue for interest purposes.
A.B. Med. Servs. PLLC v State-Wide Ins. Co. (2005 NYSlipOp 50785(U)) Appellate Term, Second DepartmentApplies (c) to preclude the provider-fraud defense because the insurer failed to pay or deny within 30 days, while preserving its defense that the collision furthered an insurance fraud scheme.
Ocean Diagnostic Imaging P.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50525(U)) Appellate Term, Second DepartmentApplies (c) to find the denials untimely from the denial forms and preclude most defenses, while preserving the insurer's defense that the injuries were not causally related to the accident.
Vista Surgical Supplies, Inc. v Travelers Ins. Co. (2006 NY Slip Op 52502(U)) Appellate Term, Second DepartmentApplies (c) to find the denials timely mailed based on an affidavit detailing the insurer's standard office mailing procedure, which created a presumption of mailing.
Summit Psychological, P.C. v General Assur. Co. (2005 NY Slip Op 25263) Appellate Term, Second DepartmentApplies (c)'s requirement to pay or deny after receipt of proof of claim in concluding that blanket denials issued before receipt of the provider's claims did not validly deny those claims.
New Millennium Med. Imaging, P.C. v GEICO (2022 NY Slip Op 22300) Appellate Term, Second DepartmentCites (c) to define the insurer's 30-day claim determination period, whose expiration fixes accrual when the insurer neither pays nor denies the claim.
Ocean Diagnostic Imaging P.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50607(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses because the insurer neither paid nor denied within 30 days nor established timely verification requests, while allowing its defense that the injuries were unrelated to the accident.
Mollo Chiropractic, PLLC v American Commerce Ins. Co. (2013 NY Slip Op 23419) Appellate Term, Second DepartmentQuotes (c) (1)'s duplicate-denial requirement in reviewing summary judgment based solely on failure to prove duplicate issuance, and recounts prior authority requiring proof that a partial-denial letter was issued in duplicate and approved by the insurance department.
Brooklyn Chiropractic Assoc., P.C. v Progressive Cas. Ins. Co. (2007 NY Slip Op 27323) Appellate Term, Second DepartmentCites (c) for the 30-day payment-or-denial deadline as the starting point for calculating interest on unpaid claims, before addressing the separate rule tolling interest after receipt of a denial.
Vista Surgical Supplies, Inc. v State Farm Mut. Ins. Co. (2007 NY Slip Op 50163(U)) Appellate Term, Second DepartmentApplies (c) to preclude medical-necessity, fraudulent-billing and excessive-fee defenses because the insurer failed to prove timely mailing of its denials through personal-knowledge evidence or a sufficiently detailed office mailing procedure.
Ocean Diagnostic Imaging P.C. v Travelers Indem. Co. (2005 NY Slip Op 50644(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses because the insurer failed to demonstrate timely denial or verification tolling, while preserving its defense that the collision furthered an insurance fraud scheme.
Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 50909(U)) Appellate Term, Second DepartmentRelies on (c) in finding the insurer demonstrated timely mailing of its denial based on IME nonappearance, which, together with proof of the IME requests and the assignor's nonappearance, defeated the provider's summary judgment motion.
A.M. Med. Servs., P.C. v Nationwide Mut. Ins. Co. (2006 NY Slip Op 51425(U)) Appellate Term, Second DepartmentApplies (c) to find that an EUO request did not toll the 30-day deadline under the regulations in effect before April 5, 2002, which did not recognize EUOs as verification, leaving most defenses precluded.
Millennium Med. Instruments Inc. v NYC Tr. Auth. (2005 NY Slip Op 52205(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses because the self-insurer failed to pay or deny within 30 days, but permits the defense that the injuries were not causally related to the accident.
Careplus Med. Medical Supply Inc. v Allstate Ins. Co. (2005 NY Slip Op 51598(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while preserving its defense that the collisions furthered insurance fraud schemes.
Ocean Diagnostic Imaging P.C. v Travelers Prop. Cas. Corp. (2005 NY Slip Op 51047(U)) Appellate Term, Second DepartmentCites (c)'s 30-day rule to explain that an untimely denial precludes most defenses but leaves available the defense that the collision furthered an insurance fraud scheme, which could defeat the provider's summary judgment motion.
Gpm Chiropractic, P.C. v State Farm Mut. Ins. Co. (2005 NYSlipOp 50744(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while preserving the defense that the alleged injuries did not arise from a covered accident.
Urban Radiology, P.C. v American Tr. Ins. Co. (2009 NY Slip Op 51734(U)) Appellate Term, Second DepartmentRelies on proof of a timely denial under (c), based in part on a peer review finding no medical necessity, in finding a potentially meritorious defense supporting vacatur of the default judgment on that claim.
Freeport Med., P.C. v Utica Natl. Ins. Co. of Tex. (2008 NY Slip Op 51448(U)) Appellate Term, Second DepartmentNotes that failure to pay or deny within (c)'s 30-day period, without proof of timely verification tolling, did not preclude the insurer's lack-of-coverage defense based on an intentional loss.
Bronx Expert Radiology, P.C. v Allstate Ins. Co. (2007 NY Slip Op 50682(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses because the insurer failed to pay or deny within 30 days, while allowing its defense that the collision furthered an insurance fraud scheme despite the untimely denials.
New Century Chiropractic, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 52236(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses where the insurer neither denied within 30 days nor proved timely verification requests, while allowing the defense that the collision furthered an insurance fraud scheme despite the late denial.
Bell Air Med. Supply LLC v State Farm Ins. Claim Off. (2006 NY Slip Op 52218(U)) Appellate Term, Second DepartmentApplies (c)'s 30-day deadline to preclude most defenses to the claim whose receipt the insurer acknowledged, because the denial was late and the insurer failed to establish timely verification requests extending the deadline.
Ocean Diagnostic Imaging P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51424(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while preserving the defense that the collision furthered an insurance fraud scheme despite the untimely denial.
Delta Diagnostic Radiology, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 51345(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses because the insurer failed to pay or deny within 30 days and failed to show any tolling of its time to deny.
A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 51036(U)) Appellate Term, Second DepartmentCites (c) for the 30-day deadline to pay or deny, subject to tolling by verification requests, in evaluating the insurer's obligation after it requested the treating person's name and license.
AT Med. P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50739(U)) Appellate Term, Second DepartmentApplies (c) to find the insurer's denials untimely, while noting that timely verification requests and compliance with follow-up requirements may extend the 30-day determination period.
Jeffrey I. Rubin, Phd Psyc. Svcs., P.C. v Utica Mut. Ins. Co. (2005 NY Slip Op 52206(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while preserving the defense that the alleged injuries did not arise from an insured incident.
Ocean Diagnostic Imaging P.C. v AIU Ins. Co. (2005 NY Slip Op 52200(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while allowing its defense that the alleged injuries did not arise from a covered accident.
Corona Med. Imaging, P.C. v State Farm Ins. Cos. (2005 NY Slip Op 51685(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while preserving its defense that the collision furthered an insurance fraud scheme.
S & M Supply Inc. v State Farm Mut. Auto. Ins. Co. (2005 NYSlipOp 50747(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses after the insurer failed to pay or deny within 30 days, while allowing its defense that the collision furthered an insurance fraud scheme.
Ocean Diagnostic Imaging P.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50606(U)) Appellate Term, Second DepartmentApplies (c) to preclude most defenses because the insurer neither paid nor denied within 30 days nor established timely verification requests, while allowing its defense that the injuries were unrelated to the accident.
Dilon Med. Supply Corp. v Travelers Ins. Co. (2005 NY Slip Op 25113) Trial courtQuotes (c)'s 30-day payment-or-denial requirement as the starting point for explaining how timely verification requests extend that period in a medical supplier's suit.
Surgicare Surgical v National Interstate Ins. Co. (2014 NY Slip Op 24362) Trial courtCites (c) as part of the claim-handling schedule in rejecting the provider's untimeliness argument, explaining that additional verification tolls the 30-day period until the requested information is received.
Millennium Radiology, P.C. v New York Cent. Mut. Fire Ins. Co.(2009 NY Slip Op 50877(U)) Trial courtRelies on (c) in finding that the provider established its prima facie case through proof that prescribed billing forms were mailed and received and that payment was overdue.
Kipor Medicine P.C. v MVAIC (2009 NY Slip Op 29085) Trial courtRelies on (c)'s 30-day pay-or-deny rule to explain the provider's prima facie burden, holding that the provider need not additionally prove the assignor's New York residency where claim receipt and failure to pay or deny within 30 days were stipulated.
SK Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 26227) Trial courtRelies on (c) to establish that the insurer timely denied the claims on medical necessity grounds, preserving that defense before considering whether a substitute peer expert could testify.
RJ Med., P.C. v All-State Ins. Co. (2007 NY Slip Op 51061(U)) Trial courtCites (c) with other authorities for the proposition that proof of a properly submitted claim form or substantial equivalent establishes the provider's prima facie case and shifts the burden to the insurer to establish lack of medical necessity.
Maple Med. Acupuncture, P.C. v Motor Veh. Acc. Indem. Corp. (2007 NY Slip Op 50827(U)) Trial courtRelies on (c) to measure the three-year limitations period from when payment becomes overdue, 30 days after receipt of the claims, while requiring no prior determination that the assignor is a qualified person.
Jeff Mollins, D.C v GEICO (2007 NY Slip Op 50467(U)) Trial courtCites (c) for the provider's prima facie summary judgment burden to prove claim submission, the fact and amount of loss, and overdue payment, shifting the burden to the insurer to raise a triable issue.
DWP Pain Free Med. P.C. v Progressive Northeastern Ins. Co. (2006 NY Slip Op 26531) Trial courtCites (c) for the requirement that the insurer generate and mail a denial within 30 days of receiving the claim, subject to extension through timely verification demands, in a dispute over signature verification.
Chiropractic Neurodiagnostics, P.C. v Travelers Indem. Co. (2006 NY Slip Op 26049) Trial courtCites (c)'s 30-day pay-or-deny requirement and rule on preclusion of defenses in addressing the insurer's objection that the provider lacked a valid assignment of benefits.
First Help Acupuncture, P.C. v Lumbermens Mut. Ins. Co. (2005 NY Slip Op 51815(U)) Trial courtCites (c) in requiring admissible proof of claim submission and overdue benefits for a provider's prima facie summary judgment showing, without which the insurer need not raise a triable issue.
A.B. Med. Servs. PLLC v Countrywide Ins. Co. (2005 NY Slip Op 25424) Trial courtRelies on (c) as an alternative reason to refuse amendment of defective proofs of claim at trial, because proceeding immediately on amended claims would deny the insurer its allotted opportunity to pay or deny.
In Line Chiropractic, P.C. v Motor Veh. Acc. Indem. Corp. (2005 NY Slip Op 50275(U)) Trial courtCites (c)'s 30-day payment-or-denial requirement and resulting overdue status in analyzing when the provider's claim accrues for limitations purposes.
Renelique v Foremost Signature Ins. Co. (2023 NY Slip Op 51226(U)) Trial courtCites (c) for the 30-day pay-or-deny rule after finding that the provider established mailing, receipt and overdue payment.
Sloan v Nationwide Mut. Ins. Co. (2022 NY Slip Op 50997(U)) Trial courtCites (c) for the 30-day pay-or-deny deadline, before stating that failure to establish timely payment or denial precludes the insurer's defense to nonpayment.
Alsaad Med., P.C. v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op50532(U)) Trial courtCites (c) for the insurer's 30-day payment-or-denial deadline and explains, in analyzing the provider's EUO nonappearance, that proper verification requests can extend it.
Kings County Physicians Group v Nationwide Ins. Co. (2021 NY Slip Op 50337(U)) Trial courtCites (c) for the 30-day payment-or-denial deadline and explains that failure to establish timely denial precludes the insurer's defense to nonpayment.
Tian Shan Acupuncture PC v Global Liberty Ins. Co. (2019 NY Slip Op 50728(U)) Trial courtRelies on (c)'s 30-day payment-or-denial rule in finding that the insurer's same-day IME request timely extended the period pending verification.
Global Liberty Ins. Co. of N.Y. v Otero (2018 NY Slip Op 51025(U)) Trial courtRelies on (c) to support the insurer's right to deny all claims retroactively to the date of loss after the assignor failed to appear for requested IMEs, treating nonappearance as a breach of a condition precedent to coverage.
MVAIC v Stand-Up MRI of Manhattan, P.C. (2011 NY Slip Op 51187(U)) Trial courtRelies on (c) to require the insurer to act on a verification response by paying, denying, or seeking further verification if the response is insufficient, rather than leaving the claim unresolved.
Lenox Hill Hosp. v Allstate Ins. Co. (2011 NY Slip Op 50800(U)) Trial courtCites (c) for the rule that payment or denial awaits all timely demanded verification when examining whether the insurer's verification request was timely.
Craigg Total Health Family Chiropractic Care PC v QBE Ins. Corp. (2008 NY Slip Op51398(U)) Trial courtCites (c) as part of the providers' prima facie summary judgment burden to prove proper claim submission and failure to pay or properly deny within the prescribed period; their supporting documents required a business-record foundation.
Westchester Med. Ctr. v Mercury Cas. Co. (2008 NY Slip Op 28287) Trial courtCites (c)'s 30-day pay-or-deny rule and explains that an insurer that neither timely denies nor extends its deadline through verification requests is precluded from asserting the intoxication exclusion.
Lenox Hill Radiology MIA, P.C. v American Tr. Ins. Co. (2008 NY Slip Op 28053) Trial courtRelies on (c)'s 30-day payment-or-denial deadline to reject an interpretation allowing untimely verification requests to delay claim processing.
Capri Med., P.C. v Auto One Ins. Co. (2006 NY Slip Op 52413(U)) Trial courtApplies (c) to find the provider's prima facie entitlement to summary judgment established by admissible proof of claim submission and overdue payment, including the billing manager's assertion of personal mailing.
Chiropractic Neurodiagnosis, PC v Travelers Indem. Co. (2006 NY Slip Op 50257(U)) Trial courtCites (c)'s 30-day pay-or-deny requirement as the framework for competing summary judgment motions involving the timeliness of a medical-necessity denial.
City Wide Social Work & Psychological Servs., P.L.L.C. v General Assur. Co. (2005 NY Slip Op 51197(U)) Trial courtCites (c) for the provider's prima facie burden to submit admissible proof of claim submission, the fact and amount of loss, and overdue payment, after which the insurer must raise a triable issue.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2015 NY Slip Op 04787) Court of AppealsCites (c) for the insurer's duty to pay or deny within 30 days after receiving a verification of treatment form, noting that the insurer denied one claim and did not respond to the others.
Fair Price Med. Supply Corp. v Travelers Indem. Co. (2008 NY Slip Op 04946) Court of AppealsQuotes another decision citing (c) for the insurer's duty to pay or deny within 30 calendar days after receipt of proof of claim, as background to the dispute over preclusion of a nondelivery defense.
Aetna Health Plans v Hanover Ins. Co. (2016 NY Slip Op 04658) Court of AppealsCites (c) in the concurrence to support the view that allowing a health insurer equitable subrogation against a no-fault insurer would conflict with the no-fault scheme's insistence on timely claim resolution.
East Acupuncture, P.C. v Allstate Ins. Co. (2009 NY Slip Op 01191) Appellate Division, Second DepartmentQuotes (c)'s requirement to pay or deny within 30 days of receiving proof of claim in outlining the regulatory framework for the dispute over interest on overdue benefits.
American Tr. Ins. Co. v Longevity Med. Supply, Inc. (2015 NY Slip Op 06761) Appellate Division, First DepartmentNotes that the dissent cites (c) in describing a prior holding that IME nonappearance permits retroactive denial regardless of whether the denials were timely issued.
Globe Surgical Supply v GEICO Ins. Co. (2008 NY Slip Op 10583) Appellate Division, Second DepartmentCites (c)'s 30-day payment-or-denial deadline as part of the regulatory background to a proposed class action challenging reductions in reimbursement for durable medical equipment.
Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 05779) Appellate Division, Second DepartmentQuotes another decision's rule under (c) that an insurer failing to deny or seek verification within 30 days after proof of claim waives defenses other than complete absence of coverage.
Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2019 NY Slip Op 06059) Appellate Division, Second DepartmentQuotes an earlier decision's rule, citing (c), that an insurer must pay, deny, or seek verification within 30 days, as background to the dispute over denying a claim for insufficient information without requesting verification.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2007 NY Slip Op 06865) Appellate Division, Second DepartmentNotes the provider's showing that the insurer neither paid nor denied within the 30 days required by (c), before addressing the insurer's timely requests for intoxication verification.
Contemp. Med. Diag. & Treatment, P.C. v Government Employees Ins. Co. (2005 NY Slip Op 50254(U)) Appellate Term, Second DepartmentNotes the provider's argument under (c) that payment or denial was required within 30 days of claim receipt and that no timely verification request extended that period.
S&m Supply Inc. v Lancer Ins. Co. (2004 NY Slip Op 50695(U)) Appellate Term, Second DepartmentNotes the provider's argument under (c) that the denial was untimely because the insurer failed to pay or deny within 30 days, against the insurer's contention that verification and EUO requests tolled that period.
King’S Med. Supply v Kemper Auto & Home Ins. Co. (2004 NY Slip Op 50401(U)) Appellate Term, Second DepartmentNotes the provider's reliance on the 30-day payment-or-denial rule now in (c) as a ground for summary judgment on its medical-supply claim.
Bronx Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 27427) Appellate Term, First DepartmentQuotes, in a concurrence, another decision's application of (c) to preclude most defenses after an untimely denial while preserving a defense that the injuries were causally unrelated to the accident, in discussing the scope of that exception.
S & M Supply, Inc. v Nationwide Mut. Ins. Co. (2004 NY Slip Op 50557(U)) Appellate Term, Second DepartmentNotes the provider's reliance on the 30-day payment-or-denial rule now in (c) to challenge a denial based on the assignor's EUO nonappearance.
Urban Well Acupuncture, P.C. v American Commerce Ins. Co. (2014 NY Slip Op 51520(U)) Appellate Term, First DepartmentNotes that (c) raises the question whether a denial may be mailed to the treating acupuncturist rather than the provider corporation, but leaves that question open because the insurer failed to establish mailing.
Boai Zhong Yi Acupuncture Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51202(U)) Appellate Term, Second DepartmentNotes the provider's argument under (c) that summary judgment was warranted because the insurer failed to pay or deny within 30 days of claim receipt; the insurer asserted that timely verification requests tolled that period.
Canarsie Med. Health, P.C. v National Grange Mut. Ins. Co. (2008 NY Slip Op 28380) Trial courtCites (c)'s 30-day payment-or-denial deadline after proper verification, subject to further verification requests, as background to its review of interest suspension when a provider delays challenging a denial.
Greater Forest Hills Physical Therapy, PC v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51594(U)) Trial courtQuotes an agency opinion invoked by the insurer treating (c) as requiring a separate payment or denial for every submitted claim despite an earlier IME-based denial of all future benefits.
American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U)) Trial courtQuotes (c) from precedent for the 30-day pay-or-deny rule as the baseline deadline subject to tolling for additional verification.
Heavenly Points Acupuncture v Integon Natl. Ins. Co. (2021 NY Slip Op 50895(U)) Trial courtCites (c) for the 30-day pay-or-deny deadline and the rule precluding an insurer from offering a nonpayment defense without establishing timely denial, as background to its medical-necessity analysis.
Apazidis, M.D., P.C. v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op 50498(U)) Trial courtCites (c) for the insurer's 30-day payment-or-denial deadline in an action involving requests for documentary verification of the provider's reimbursement eligibility.
IAV Med. Supply, Inc. v Progressive Ins. Co. (2010 NY Slip Op 50433(U)) Trial courtQuotes another decision citing (c) for timely medical-necessity denials, as part of its explanation for allowing a substitute expert to testify to the original peer review's facts and opinions.
SCOB, LLC v Liberty Mut. Ins. Co. (2026 NY Slip Op 51484(U)) Trial courtCites (c) for the 30-day payment-or-denial deadline and explains that failure to establish timely payment or denial precludes defenses to nonpayment, before addressing defects in the insurer's IME notice and nonappearance proof.
Cuevas v Everest Denali Ins. Co. (2025 NY Slip Op 52120(U)) Trial courtNotes the claimant's reliance on (c) (1)'s denial-form requirement and the 30-day payment-or-denial deadline to challenge the insurer's disclaimer.
Jiang Acupuncture PC v State Farm Ins. Co. (2023 NY Slip Op 50961(U)) Trial courtCites (c) for the 30-day pay-or-deny deadline in outlining the rules governing the competing summary judgment motions.
American Tr. Ins. Co. v Nexray Med. Imaging PC (2023 NY Slip Op50538(U)) Trial courtQuotes (c) from precedent for the insurer's 30-day obligation to pay or deny, subject to an extension for timely additional verification requests.
Advanced Recovery Equip. & Supplies v Travelers Ins. Co. (2022 NY Slip Op 50690(U)) Trial courtCites (c) for the 30-day pay-or-deny deadline and the general preclusion rule while addressing the parties' fee-schedule summary judgment motions.
New York Med. & Diagnostic Ctr. v GEICO Ins. Co. (2021 NY Slip Op 51138(U)) Trial courtCites (c) for the 30-day pay-or-deny deadline and the general consequence of preclusion for untimely denial, as background to the insurer's late-submission and fee-schedule defenses.
Chiropractic Exam Works, P.C. v Sentry Cas. Co. (2021 NY Slip Op 51125(U)) Trial courtCites (c) for the 30-day pay-or-deny requirement and the rule precluding defenses when timely payment or denial is not established, in addressing the insurer's misrepresentation and EUO defenses.
Sabodash v Hereford Ins. Co. (2021 NY Slip Op 51099(U)) Trial courtCites (c) for the general 30-day pay-or-deny rule before discussing verification extensions, in an action resolved on the insurer's unsupported lack-of-coverage defense.
Advanced Recovery E. & S. v MVAIC (2021 NY Slip Op 51035(U)) Trial courtCites (c) for the 30-day pay-or-deny rule and preclusion of untimely defenses while considering the insurer's coverage obligations to the assignor.
New York Core Chiropractic, P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50599(U)) Trial courtCites (c) for the 30-day payment-or-denial deadline and explains that failure to establish timely payment or denial precludes the insurer from offering its defense to nonpayment.
Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims (2021 NY Slip Op 50523(U)) Trial courtCites (c) for the 30-day deadline after receipt of proof of claim before explaining how timely verification requests can extend or toll that period.
Advanced Recovery v Allstate Ins. Co. (2021 NY Slip Op 21148) Trial courtCites (c) for the insurer's 30-day payment-or-denial deadline and explains that failure to establish timely payment or denial precludes evidence of a defense to nonpayment.
NY Wellness Med. P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50382(U)) Trial courtCites (c) for the 30-day payment-or-denial deadline and the preclusion consequences of failing to establish compliance, in an action involving EUO-based denials.
Sabas v MVAIC (2021 NY Slip Op 50313(U)) Trial courtCites (c) for the 30-day pay-or-deny rule and resulting preclusion of defenses in discussing the insurer's obligations while addressing whether the assignor qualified for benefits.
Happy Apple Med. Servs., PC v Liberty Mut. Ins. Co. (2021 NY Slip Op 50336(U)) Trial courtCites (c) for the need to deny within 30 days to invoke a work-related-accident exclusion, but leaves denial and preclusion issues undecided because the motion concerns subject matter jurisdiction.
Sayyed DC, P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50311(U)) Trial courtCites (c) for the 30-day payment-or-denial rule and explains that failure to establish timely denial precludes a defense to nonpayment, in considering the insurer's EUO nonappearance defense.
Pro-Align Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50341(U)) Trial courtCites (c) for the general 30-day payment-or-denial rule before explaining how verification requests extend that period; the dispute ultimately concerns reimbursement for nerve conduction studies under the fee schedule.
New York Hosp. Med. Ctr. of Queens v Countrywide Ins. Co. (2009 NY Slip Op 50764(U)) Trial courtCites (c)'s requirement to pay or deny within 30 days of receiving a claim and explains that a timely demand for further verification may extend that period.
Webster Ave. Med., P.C. v Travelers Prop. Cas. (2004 NY Slip Op 51526(U)) Trial courtNotes that the parties stipulated to timely service of the insurer's denials under (c), leaving their adequacy and the peer review doctor's qualifications for consideration.

Subdivision (d) (1 decision)

Surgicare Surgical v National Interstate Ins. Co. (2014 NY Slip Op 24362) Trial courtApplies (d) to reject the contention that partial payment showed acceptance of the entire claim, preserving the insurer's fee-schedule defense because payment of undisputed benefits is without prejudice.

Subdivision (e) (7 decisions)

Nationwide Gen. Ins. Co. v South (2024 NY Slip Op 00028) Appellate Division, First DepartmentApplies (e) (2) to uphold denial of coverage based on a founded belief that the collision was not covered, supported by investigation and the driver's EUO testimony that a passenger directed someone to hit the car.
Universal Open MRI of the Bronx, P.C. v State Farm Mut. Auto Ins. (2006 NY Slip Op 50853(U)) Trial courtHolds that a staged collision defense under (e) (2) requires admissible trial evidence showing the collision more likely than not was not covered, rather than proof of common-law fraud.
Westchester Med. Ctr. v Clarendon Natl. Ins. Co. (2008 NY Slip Op 09786) Appellate Division, Second DepartmentCites (e), together with the intoxication-verification provision, in finding a triable issue whether the insurer timely and properly denied coverage within 30 days after receiving requested verification of the assignor's alleged intoxication.
V.S. Med. Servs., P.C. v Allstate Ins. Co. (2006 NY Slip Op 26000) Trial courtCites (e) (2) to explain that a staged collision defense concerns a noncovered incident, with the inquiry focusing on whether the collision was deliberate rather than whether it resulted from fraudulent motivation.
New York Massage Therapy P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 52573(U)) Trial courtCites (e) (2) as authorizing denial of a staged-accident claim upon a founded belief of no coverage, requiring admissible evidence supporting that belief before the burden shifts to the provider.
T&G Med. Supplies, Inc. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 50636(U)) Trial courtRelies on (e) to distinguish a lack-of-coverage defense, which survives an untimely denial, from policy-condition or exclusion defenses subject to preclusion.
Complete Orthopedic Supplies, Inc. v State Farm Ins. Co. (2007 NY Slip Op 27192) Trial courtCites (e), in a survey of defenses, for lack-of-coverage arguments that an injury did not arise from an insured incident, including staged accidents or injuries having an independent cause.

Subdivision (f) (2 decisions)

Lenox Hill Radiology MIA, P.C. v American Tr. Ins. Co. (2008 NY Slip Op 28053) Trial courtRejects the insurer's interpretation of (f) as permitting untimely verification requests to postpone payment, construing the provision to preserve only proper, timely verification requests within the claim-processing framework.
A.B. Med. Servs. PLLC v GEICO Gen. Ins. Co. (2008 NY Slip Op 52641(U)) Trial courtQuotes (f) for the rule that failing to observe the section's time frames does not prevent an insurer from requiring proper proof of claim.

Subdivision (g) (31 decisions)

Oleg’s Acupuncture, P.C. v Hereford Ins. Co. (2018 NY Slip Op 50095(U)) Appellate Term, Second DepartmentHolds that (g) (1) (ii) and (2) preserve a fee-schedule defense without a timely denial for services rendered on or after April 1, 2013, granting insurer summary judgment upon unrebutted coding evidence of full payment.
Excel Surgery Ctr., LLC v Metropolitan Prop. & Cas. Ins. Co. (2019 NY Slip Op 51843(U)) Appellate Term, Second DepartmentHolds that (g) (1) (ii) preserves a fee schedule defense without proof of a timely denial for services covered by (g) (2), rejecting the provider's challenge to the insurer's denial mailing.
Z. M. S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51891(U)) Appellate Term, Second DepartmentApplies (g) to hold the fee-schedule defense not subject to preclusion for services rendered after April 1, 2013, granting dismissal where the insurer established full payment for acupuncture under the chiropractic fee schedule and the provider failed to rebut that showing.
Precious Acupuncture Care, P.C. v Hereford Ins. Co. (2018 NY Slip Op 50042(U)) Appellate Term, Second DepartmentApplies (g) (1) (ii) and (2) to hold that timely denials were unnecessary to preserve the fee-schedule defense for services rendered after April 1, 2013, granting dismissal where coding evidence established full payment and counsel's affirmation raised no factual issue.
Live In Grace Acupuncture, P.C. v GEICO Gen. Ins. Co. (2020 NY Slip Op 51360(U)) Appellate Term, Second DepartmentApplies (g) (1) (ii) and (2) to dismiss acupuncture claims because the insurer proved full payment under the workers' compensation fee schedule.
Parisien v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51602(U)) Appellate Term, Second DepartmentApplies (g) (1) (ii) and (g) (2) to affirm dismissal of claims for charges exceeding the workers' compensation fee schedule where the services were rendered after the regulation took effect.
East Coast Acupuncture, P.C. v Hereford Ins. Co. (2016 NY Slip Op 26042) Trial courtHolds that (g) (1) (ii) makes the fee schedule defense nonprecludable for services rendered after April 1, 2013, while leaving overbilling an affirmative defense rather than adding fee schedule compliance to the provider's prima facie burden.
Saddle Brook Surgicenter, LLC v All State Ins. Co. (2015 NY Slip Op 25099) Trial courtHolds that (g) (1) (ii) permits an excessive-fee defense despite a denial issued after 30 days, superseding contrary authority predating the amendment and allowing summary judgment where the provider billed above the applicable New Jersey fee schedule.

Show all 31 decisions

Blano Med., P.C. v Hereford Ins. Co (2025 NY Slip Op 51540(U)) Trial courtHolds that (g) (1) does not excuse timely denial of a fee schedule defense, granting the provider a directed verdict because the insurer conceded it issued no denial on that ground.
Tyorkin v Garrison Prop. & Cas. Ins. Co. (2016 NY Slip Op 50846(U)) Trial courtHolds that (g) preserves the fee schedule defense despite an untimely denial or failure to issue a denial form, but limits reimbursement to permissible New Jersey rates rather than barring payment of the entire bill merely because it was excessive.
Yumi Acupuncture, P.C. v 21st Century Ins. Co. (2026 NY Slip Op 50433(U)) Trial courtRejects the interpretation of (g) (1) (ii) that makes fee schedule defenses nonprecludable, finding the insurer's defense untimely because its verification requests addressed only other insurance and did not include fee schedule verification.
USAA Gen. Indem. Co. v New York Chiropractic & Physical Therapy, PLLC (2018 NY Slip Op 28133) Trial courtHolds that (g) (1) (ii) eliminates preclusion of the fee schedule defense, allowing the insurer to raise the provider's failure to comply with fee schedule ground rules.
Jing Luo Acupuncture, P.C. v NY City Tr. Auth. (2018 NY Slip Op 51083(U)) Appellate Term, Second DepartmentRelies on (g) (1) (ii) and (g) (2) when assessing acupuncture reimbursement under the chiropractic fee schedule, recognizing that no payment is due for charges exceeding the applicable schedule.
JFL Med. Care, P.C. v Wesco Ins. Co. (2022 NY Slip Op 51376(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) for the fee-schedule defense's exemption from preclusion, leaving that alternate branch of the insurer's summary judgment motion for determination on remittal.
Island Life Chiropractic Pain Care, PLLC v Zipcar (2021 NY Slip Op 50844(U)) Appellate Term, Second DepartmentRejects, under (g), the provider's assertion that the fee schedule defense was subject to preclusion, as one basis for denying the motion to strike defenses.
Gl Acupuncture, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50842(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) by comparison when denying the insurer summary judgment on its fee schedule defense for services predating the amendment, because its affidavits failed to establish timely mailing of denials.
Comprehensive Care Physical Therapy, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50848(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) by comparison when denying the insurer summary judgment on its fee schedule defense for services predating the amendment, because its affidavits failed to establish timely mailing of denials.
Gl Acupuncture, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50841(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) by comparison when denying the insurer summary judgment on its fee schedule defense for services predating the amendment, because its affidavits failed to establish timely mailing of denials.
Gl Acupuncture, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50830(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) by comparison when denying the insurer summary judgment on its fee schedule defense for services predating the amendment, because its affidavits failed to establish timely mailing of denials.
Gl Acupuncture, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50829(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) by comparison when denying the insurer summary judgment on its fee schedule defense for services predating the amendment, because its affidavits failed to establish timely mailing of denials.
Mind & Body Acupuncture, P.C. v Allstate Ins. Co. (2018 NY Slip Op 50779(U)) Appellate Term, Second DepartmentCites (g) (1) (ii) by comparison in denying insurer summary judgment on a fee-schedule defense for services rendered before April 1, 2013, because its mailing affidavits failed to establish timely denials and preservation of that defense.
Surgicare Surgical Assoc. v National Interstate Ins. Co. (2015 NY Slip Op25338) Appellate Term, First DepartmentRelies on (g) to reject preclusion of the excessive-fee defense for services rendered after the amendment's effective date, in affirming reimbursement limited to the New Jersey fee schedule.
Harvey Family Chiro PT & Acup, PLLC v Ameriprise Ins. Co. (2020 NY Slip Op 20136) Trial courtCites (g) (1) to place on the insurer the burden of establishing that the provider's charges exceeded the fee schedule before the provider must justify its billing.
MUA Chiropractic Healthcare, PLLC v State Farm Mut. Auto. Ins. Co. (2019 NY Slip Op 29375) Trial courtExamines whether (g) (1) (ii) can remove fee schedule defenses from statutory preclusion, reasoning that an agency regulation may not circumvent the legislature's 30-day payment-or-denial requirement.
Pavlova v Allstate Ins. Co. (2016 NY Slip Op 26123) Trial courtRejects the insurer's argument that (g) (1) generally requires providers to prove fee schedule compliance as part of their prima facie case, explaining that the amendment instead makes the fee schedule defense nonprecludable, separately from the provider's obligation to supply By Report information.
Advanced Recovery Equip. & Supplies v Travelers Ins. Co. (2022 NY Slip Op 50690(U)) Trial courtCites (g) (1) (ii) for the rule that no payment is due for charges exceeding fee-schedule limits, providing the legal basis for the insurer's fee-schedule defense.
New York Med. & Diagnostic Ctr. v GEICO Ins. Co. (2021 NY Slip Op 51138(U)) Trial courtCites (g) (1) (ii) for the rule that no payment is due for charges exceeding fee-schedule limits, as the governing limit underlying the insurer's fee-schedule defense.
Tandingan PT PC v State Farm Fire & Cas. Co. (2021 NY Slip Op 50869(U)) Trial courtCites (g) (1) (ii) for the rule barring payment above permissible charges when addressing the provider's claim for the unpaid balance of a bill the insurer had partially paid.
Pro-Align Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50341(U)) Trial courtRelies on (g) (1) (ii) to limit reimbursement to permissible fee-schedule charges, in dismissing claims where the insurer established full payment through coding evidence and the provider offered only unsupported attorney assertions.
Advanced Recovery Equip. & Supplies, LLC v Maya Assur. Co. (2018 NY Slip Op 50022(U)) Trial courtRelies on (g) (1) (ii) to permit a fee schedule defense despite facially untimely denials, while requiring the insurer to prove that the provider billed above the applicable schedule.
Optimal Well-Being Chiropractic, P.C. v Utica Mut. Ins. Co. (2014 NY Slip Op 51233(U)) Appellate Term, Second DepartmentNotes in a footnote that (g) would exempt the services-not-provided defense from preclusion if the treatment had been rendered after April 1, 2013, but that revised rule did not apply to the treatment at issue.

Subdivision (h) (4 decisions)

Sheepshead Bay Med. Supply, Inc. v Erie Ins. Co. of N.Y. (2021 NY Slip Op 50491(U)) Appellate Term, Second DepartmentRelies on (h) to support the validity of outdated denial forms that contained substantially the same pertinent information as the prescribed form.
Alpine Chiropractic, P.C. v Integon Natl. Ins. Co. (2020 NY Slip Op 51332(U)) Appellate Term, Second DepartmentCites (h) in concluding that the provider raised no triable issue of fact opposing summary judgment based on the assignor's IME nonappearance.
First Care Med. Equip., LLC v Kemper Ins. Co. (2020 NY Slip Op 51326(U)) Appellate Term, Second DepartmentNotes under (h) that a nonsubstantive technical defect concerning the date requested verification was received did not invalidate the denial, while denying the provider summary judgment because medical necessity remained disputed.
SB Chiropractic, P.C. v GEICO Ins. Co. (2022 NY Slip Op 50316(U)) Trial courtCites (h) for the rule that non-substantive technical or immaterial defects or omissions do not invalidate a denial, in its discussion of proof that denial forms were timely mailed.

Subdivision (i) (9 decisions)

Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2008 NY Slip Op 04866) Appellate Division, Second DepartmentApplies (i) (then (g)) to explain that requested intoxication information delays completion of proof of claim, rejecting the provider's renewed summary judgment request because it failed to establish that the insurer's verification requests were untimely or improper.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2007 NY Slip Op 06865) Appellate Division, Second DepartmentApplies (i) (then (g)) to hold the provider's claim premature because the insurer timely requested verification of the assignor's alleged intoxication and never received it, affirming dismissal of the complaint.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2008 NY Slip Op 50675(U)) Trial courtApplies (i) (then (g)) to limit intoxication verification to information within the provider's or claimant's control or obtainable through reasonable effort, while denying the insurer entitlement to all available information where treatment concerned a fall rather than motor vehicle use.
Westchester Med. Ctr. v Mercury Cas. Co. (2008 NY Slip Op 28287) Trial courtHolds that (i) (then (g)) keeps proof of claim incomplete pending requested intoxication information, including information obtainable by the provider or assignor through reasonable effort, and rejects the provider's claim that the information was outside its custody or control.
East Acupuncture, P.C. v Allstate Ins. Co. (2009 NY Slip Op 01191) Appellate Division, Second DepartmentCites (i) (then (g)) as an example of a provision using applicant specifically for an injured person, supporting its conclusion that the regulations do not use that term consistently when construing the interest toll for provider assignees.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2008 NY Slip Op 04867) Appellate Division, Second DepartmentCites (i) (then (g)) as authorizing requests for information about suspected accident-contributing intoxication that extend the ordinary 30-day payment-or-denial period when a denial rests on the intoxication exclusion.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2007 NY Slip Op 09770) Appellate Division, Second DepartmentCites (i) (then (g)) to explain that suspected intoxication contributing to an accident entitles the insurer to available information about the assignor's condition and extends the payment-or-denial period until requested verification completes proof of claim.
East Acupuncture, P.C. v Allstate Ins. Co. (2007 NY Slip Op 27109) Appellate Term, Second DepartmentCites (i) (then (g)) as an example where "applicant" means only the eligible injured person, supporting a contextual reading of that term when deciding whether provider assignees are subject to interest tolling.

Show all 9 decisions

Westchester Med. Ctr. v One Beacon Ins. Co. (2008 NY Slip Op 52580(U)) Trial courtCites (i) (then (g)) to explain that suspected intoxication contributing to an accident permits requests for condition information and leaves proof of claim incomplete until that information is supplied, rather than allowing an unrestricted lack-of-coverage defense.

Subdivision (l) (44 decisions)

Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2024 NY Slip Op 24111) Appellate Term, Second DepartmentApplies (l) to reduce the payment-or-denial period for a late verification request, but rejects using the EUO toll to extend the deadline for new verification requested more than 30 days after receipt of claim forms.
Longevity Med. Supply, Inc. v IDS Prop. & Cas. Ins. Co. (2014 NY Slip Op 51244(U)) Appellate Term, Second DepartmentApplies (l) to reduce the denial period to 24 calendar days because the initial EUO request was six business days late, finding the denial timely when mailed 11 days after the final EUO nonappearance.
Tsatskis v State Farm Fire & Cas. Co. (2012 NY Slip Op 51268(U)) Appellate Term, Second DepartmentApplies (l) (then (j)) with the verification-request deadline to hold the insurer's denials of the first 14 claims untimely, precluding its EUO noncompliance defense and preserving judgment for the provider on those claims.
Goldstar Equip., Inc. v Mercury Cas. Co. (2018 NY Slip Op 50576(U)) Appellate Term, Second DepartmentApplies (l), with the verification-request rule, to reject the provider's challenge to proof that the EUO scheduling letters and denial forms were timely mailed.
A.C. Med., P.C. v Ameriprise Ins. Co. (2016 NY Slip Op 51787(U)) Appellate Term, Second DepartmentApplies (l) to reduce the insurer's time to pay or deny a claim by the number of days its EUO request exceeded the 15-business-day verification deadline; the insurer failed to deny within the reduced period.
St. Vincent Med. Care, P.C. v Travelers Ins. Co. (2010 NY Slip Op 50446(U)) Appellate Term, Second DepartmentApplies (l) (then (j)) with the verification deadlines to hold that EUO scheduling letters mailed 52 days after receipt of the bills did not toll the payment-or-denial period, leaving the insurer unable to raise a triable issue.
Stracar Med. Servs. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51759(U)) Appellate Term, Second DepartmentApplies (l) to reduce the denial period by one day for an EUO request mailed one business day late, finding denials mailed 21 days after the second EUO nonappearance timely.
Eagle Surgical Supply, Inc. v Allstate Indem. Co. (2013 NY Slip Op 52012(U)) Appellate Term, Second DepartmentApplies (l) (then (j)) to reduce the payment-or-denial period to 21 calendar days because the EUO request was nine days late, holding the denial timely because it followed the final EUO nonappearance by 20 days.

Show all 44 decisions

Sama Physical Therapy, P.C. v IDS Prop. Cas. Ins. Co. (2017 NY Slip Op 51751(U)) Appellate Term, Second DepartmentApplies (l) to uphold an EUO nonappearance denial despite an initial scheduling letter mailed beyond 15 business days, explaining that the late request shortened the denial period by the same number of days but the denial remained timely.
Acupuncture Healthcare Plaza I, P.C. v Allstate Ins. Co. (2017 NY Slip Op 50939(U)) Appellate Term, Second DepartmentHolds that (l) expressly excludes follow-up verification requests, so an untimely follow-up EUO notice rendered the subsequent denial untimely and precluded the nonappearance defense, entitling the provider to summary judgment.
Utopia Equip., Inc. v NY Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 51820(U)) Appellate Term, Second DepartmentApplies (l) to deny summary judgment dismissing two other claims because the insurer failed to establish as a matter of law that its denials were timely.
Danielson v Country-Wide Ins. Co. (2012 NY Slip Op 52189(U)) Appellate Term, First DepartmentHolds that under (l) (then (j)), verification requests sent after the 15-business-day request period but before the 30-day denial period expires remain valid and merely shorten the payment or denial period, warranting dismissal where the provider did not respond.
Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51337(U)) Appellate Term, Second DepartmentApplies (l) (then (j)) with the follow-up verification rule to find an IME follow-up notice untimely after the assignor's nonappearance, leaving the 30-day payment or denial period untolled and the insurer unable to establish timely denials preserving its defenses.
North N.Y. Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 51557(U)) Appellate Term, Second DepartmentApplies (l) (then (j)) to reduce the insurer's payment or denial period to 28 days because its verification request was two business days late, making the subsequent denial untimely.
Pine Hollow Med., P.C. v Global Liberty Ins. Co. of N.Y. (2009 NY Slip Op 29264) Trial courtInterprets (l) (then (j)) as excluding follow-up verification requests from its time-reduction rule, but reasons that a follow-up sent one day late should not eliminate tolling when a similarly late additional verification request merely shortens the eventual payment-or-denial period.
Prestige Med. P.C. v Travelers Home & Mar. Ins. Co. (2014 NY Slip Op 24317) Trial courtApplies (l) to reduce the insurer's denial period by four days because it requested the provider's EUO 19 business days after the assignor's EUO, leaving 26 days to deny after the provider's second nonappearance.
New York Core Chiropractic, P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50599(U)) Trial courtApplies (l) to hold that an initial EUO request sent two business days late, but within 30 calendar days of claim receipt, still tolled the deadline while reducing the subsequent payment-or-denial period to 28 days.
Neptune Med. Care, P.C. v Ameriprise Auto & Home Ins. (2015 NY Slip Op 51220(U)) Appellate Term, Second DepartmentRelies on (l)'s reduction of the 30-day payment or denial period for late verification requests in finding EUO requests made more than 15 business days and 30 calendar days after receipt of the bills untimely.
Acupuncture Works, P.C. v MVAIC (2010 NY Slip Op 50646(U)) Appellate Term, Second DepartmentCites (l) (then (j)) in recognizing that an initial verification request may have tolled the payment deadline, but finds no timely follow-up and holds that later denials did not postpone the payment due date.
Arco Med. NY, P.C. v Lancer Ins. Co. (2011 NY Slip Op 52384(U)) Appellate Term, Second DepartmentCites (l) (then (j)) with the verification-request timing rule in finding the initial EUO request timely, supporting tolling of the remaining claims and denial of the provider's summary judgment motion as to those claims.
Choice Health Chiropractic, P.C. v American Tr. Ins. Co. (2018 NY Slip Op 50185(U)) Appellate Term, Second DepartmentRelies on (l) in assessing an IME nonappearance denial issued within 30 days after verification was received; disputed mailing of the verification requests left denial timeliness unresolved and defeated insurer summary judgment on that claim.
Megacure Acupuncture, P.C. v Lancer Ins. Co. (2013 NY Slip Op 51994(U)) Appellate Term, Second DepartmentCites (l) (then (j)) in finding that the insurer established timely EUO nonappearance denials, supporting denial of the provider's summary judgment motion on six claims.
LMS Acupuncture, P.C. v Titan Ins. Co. (2017 NY Slip Op 51229(U)) Appellate Term, Second DepartmentCites (l) in finding that the insurer timely mailed initial and follow-up EUO notices and denials for three claims, leaving summary judgment dismissing those claims undisturbed.
MSB Physical Therapy, P.C. v Nationwide Ins. (2025 NY Slip Op 50831(U)) Appellate Term, Second DepartmentCites (l) with mailing-proof authority in finding initial and follow-up EUO notices timely mailed, supporting affirmance of summary judgment for the insurer based on the provider's nonappearance and subsequent timely, proper denials.
GPLW Acupuncture, P.C. v Nationwide Mut. Ins. Co. (2024 NY Slip Op 50397(U)) Appellate Term, Second DepartmentCites (l) with mailing-proof authority in finding the insurer's EUO notices and nonappearance denials timely mailed through standard office practices, supporting summary judgment dismissing the provider's complaint.
Lefferts Gardens Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2022 NY Slip Op 50599(U)) Appellate Term, Second DepartmentRelies on (l) in finding that the insurer timely sent verification requests, supporting dismissal of the provider's action as premature when no response was received.
K.O. Med., P.C. v IDS Prop. Cas. Ins. Co. (2019 NY Slip Op 50687(U)) Appellate Term, Second DepartmentCites (l) in finding the insurer's initial and follow-up EUO notices and denials timely for the remaining claims, supporting dismissal based on the provider's failure to appear for both EUOs.
MT Servs. P.T., P.C. v Country-Wide Ins. Co. (2017 NY Slip Op 51851(U)) Appellate Term, Second DepartmentCites (l) with verification and mailing authorities in rejecting the provider's challenge to the insurer's proof that it timely mailed initial and follow-up written verification requests.
Active Chiropractic, P.C. v Country-Wide Ins. Co. (2017 NY Slip Op 51850(U)) Appellate Term, Second DepartmentCites (l) with other authorities in finding that, after receiving the appealed claim, the insurer timely mailed initial and follow-up written verification requests, rejecting the provider's contrary contention.
Ortho Passive Motion, Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51364(U)) Appellate Term, Second DepartmentCites (l) in finding timely written verification requests and timely denials after receipt of the requested verification, supporting summary judgment for the insurer on the assignor's IME nonappearance defense.
Alrof, Inc. v Country Wide Ins. Co. (2011 NY Slip Op 52297(U)) Appellate Term, Second DepartmentRelies on (l) (then (j)), together with the verification-request rule, in finding the payment-or-denial period tolled and the IME nonappearance denial timely, creating a triable issue that defeats the provider's summary judgment motion on that claim.
Inwood Hill Med. v Allstate Ins. Co. (2004 NY Slip Op 50565(U)) Trial courtDiscusses (l) (then (j)) in reconciling late verification requests with the strict 30-day rule, stating that requests made outside 30 days cannot revive an expired payment-or-denial period.
Z.M.S. & Y. Acupuncture, P.C. v Geico Gen. Ins. Co. (2017 NY Slip Op 27189) Trial courtNotes under (l) that initial EUO demands sent one to two business days beyond the 15-business-day deadline only reduce the time allowed to issue a denial.
Quality Psychological Servs., P.C. v Hartford Ins. Co. (2013 NY Slip Op 50045(U)) Trial courtRelies on a quoted interpretation of (l) (then (j)) that late additional-verification requests made within 30 days do not reduce the payment period, while requests outside 30 days come after the clock has run.
Titan Diagnostic Imaging Servs. Inc. v State Farm Mut. Auto Ins. Co (2024 NY Slip Op 24209) Trial courtCites (l) for reducing the payment-or-denial period by an insurer's delay in requesting verification beyond 15 business days, in addressing whether a post-EUO verification request could still toll that period.
Jesa Med. Supply, Inc. v American Tr. Ins. Co. (2010 NY Slip Op 20231) Trial courtApplies (l) (then (j)) to reduce the insurer's 30-day payment-or-denial period for an untimely verification request, in reconsidering whether exclusion of a legal holiday made the request one day late rather than two.
Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067) Court of AppealsCites (l) (then (j)) for reducing the insurer's payment-or-denial period when verification is requested after the prescribed request deadline but before the 30-day denial window expires.
Arco Med. NY, P.C. v Lancer Ins. Co. (2012 NY Slip Op 52178(U)) Appellate Term, Second DepartmentCites (l) (then (j)) with other authorities concerning the insurer's denial based on the provider's failure to appear for EUOs.
New Millennium Med. Imaging, P.C. v GEICO (2022 NY Slip Op 22300) Appellate Term, Second DepartmentQuotes another decision's explanation that (l) (then (j)) reduces the 30-day pay-or-deny period when verification is requested late but before that period expires, in discussing when the cause of action accrues.
Sabodash v Hereford Ins. Co. (2021 NY Slip Op 51099(U)) Trial courtCites (l) (then (j)) for the rule that a late verification request remains valid but shortens the insurer's 30-day pay-or-deny period by the delay in making the request.
Alsaad Med., P.C. v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op50532(U)) Trial courtCites (l) (then (j)) for the rule that a late verification request remains valid but shortens the insurer's 30-day payment-or-denial period by the number of days the request was late.
Tian Shan Acupuncture PC v Global Liberty Ins. Co. (2019 NY Slip Op 50728(U)) Trial courtCites (l) (then (j)) for the rule that a late verification request remains effective but reduces the insurer's 30-day period to pay or deny after verification is received by the number of days of delay.
Pro-Align Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 50341(U)) Trial courtCites (l) (then (j)) for the rule that a verification request sent beyond the applicable deadline remains valid but shortens the payment-or-denial period by the number of days late, in a general discussion preceding the fee-schedule analysis.
Sure Way NY, Inc. v Travelers Ins. Co. (2016 NY Slip Op 26413) Trial courtCites (l) in discussing prior decisions reducing the 30-day payment or denial period by the number of days an additional verification or EUO request was late.

Section cited without a subdivision (53 decisions)

Matter of Travelers Indem. Co. of Conn. v Glenwood Med., P.C. (2008 NY Slip Op 01598) Appellate Division, First DepartmentHolds that reconsideration prompted by unsolicited medical information does not move claim accrual from the section's payment due date to a second denial, and permanently stays arbitration demanded outside the six-year limitations period.
Abruscato v Allstate Prop.& Cas. Ins. Co. (2018 NY Slip Op 07279) Appellate Division, Second DepartmentApplies the section to dismiss the claimant's lost-wage claim because no reimbursement claim had been submitted, so the insurer's obligation to pay or deny never arose.
Kings Highway Diagnostic Imaging, P.C. v MVAIC (2008 NY Slip Op 28157) Appellate Term, Second DepartmentHolds that a purported verification request issued after payment became overdue could not postpone the section's payment due date or claim accrual, resulting in dismissal under the three-year limitations period.
DJS Med. Supplies, Inc. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51304(U)) Appellate Term, Second DepartmentApplies the section to establish that a first-party no-fault cause of action accrues 30 days after receipt of the claim when determining whether the action is barred by the six-year contract limitations period.
J.M. Chiropractic Servs., PLLC v State Farm Mut. Ins. Co. (2012 NY Slip Op 51348(U)) Appellate Term, Second DepartmentApplies the section's 30-day claim determination period in finding no proven toll because EUO mailing certificates lacked an affidavit establishing actual mailing or office mailing procedures, supporting denial of the insurer's dismissal motion.
Shtarkman v MVAIC (2008 NY Slip Op 51447(U)) Appellate Term, Second DepartmentUses the section's payment due date, implicitly alleged through the provider's demand for interest 30 days after claim submission, to find the action time-barred, without requiring the insurer to disprove verification tolling in its prima facie showing.
Boulevard Multispec Med., P.C. v MVAIC (2008 NY Slip Op 50872(U)) Appellate Term, Second DepartmentHolds that a verification request issued after the section's payment due date cannot postpone claim accrual, even through the provider's voluntary compliance or unilateral waiver of the request deadline, and dismisses the action under the three-year limitations period.
Advanced Med., P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51023(U)) Appellate Term, Second DepartmentHolds that the insurer's failure to prove timely mailing of EUO scheduling letters prevented it from establishing tolling of the section's 30-day determination period or timely denials preserving its EUO nonappearance defense.

Show all 53 decisions

Infinity Health Prods., Ltd. v Progressive Ins. Co. (2010 NY Slip Op 51334(U)) Appellate Term, Second DepartmentApplies the section's 30-day determination period to hold that failure to prove timely mailing of EUO scheduling letters left the insurer unable to establish tolling or timely denials and avoid preclusion of its EUO nonappearance defense.
Great Wall Acupuncture, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52308(U)) Appellate Term, Second DepartmentApplies the section to preclude the insurer's fee-schedule defense to an unpaid claim balance because it failed to establish a timely denial, entitling the provider to summary judgment on that balance.
Modern Psychiatric Servs. P.C. v Progressive Ins. Co. (2006 NY Slip Op 50143(U)) Appellate Term, Second DepartmentApplies the section's 30-day claim determination rule to preclude most defenses, including assignment deficiencies, because the insurer failed to prove timely mailing of verification requests through personal knowledge or adequate office mailing procedures.
Superior Oxygen & Ortho Supplies, Ltd. v Auto One Ins. Co. (2012 NY Slip Op 50348(U)) Appellate Term, Second DepartmentApplies the section's 30-day period in granting provider summary judgment because the insurer failed to prove timely EUO notices or tolling and therefore failed to establish timely denials preserving its EUO nonappearance defense.
Cautious Care Med., P.C. v Omni Indem. Co. (2020 NY Slip Op 51384(U)) Appellate Term, Second DepartmentApplies the section's 30-day payment period to fix accrual of a first-party no-fault cause of action 30 days after claim receipt when assessing the insurer's statute-of-limitations defense.
Essential Acupuncture Servs., P.C. v Ameriprise Auto & Home Ins. (2012 NY Slip Op 52404(U)) Appellate Term, Second DepartmentApplies the section's 30-day claim determination period to reject the insurer's EUO defense because deficient proof of timely mailing of scheduling letters failed to establish tolling, timely denials or freedom from preclusion.
EBM Med. Health Care, P.C. v Amica Mut. Ins. Co. (2011 NY Slip Op 51720(U)) Appellate Term, Second DepartmentApplies the section's rule that benefits become overdue 30 days after receipt of proof of claim to determine when a no-fault cause of action accrues for the six-year contract limitations period.
D.S. Chiropractic, P.C. v Country-Wide Ins. Co. (2009 NY Slip Op 51584(U)) Appellate Term, Second DepartmentApplies the section's 30-day determination period to hold that ineffective verification follow-ups mailed on the 30th calendar day did not toll the deadline, leaving the insurer's denials untimely and most defenses precluded.
Arguelles M.D., P.C. v American Ind. Ins. Co. (2022 NY Slip Op 50926(U)) Appellate Term, Second DepartmentApplies the section's 30-day payment rule to determine the due date from the provider's own submission and interest allegations, holding the action time-barred because it began after the six-year contract limitations period expired.
Vincent Med. Servs., P.C. v Omni Indem. Co. (2022 NY Slip Op 50141(U)) Appellate Term, Second DepartmentApplies the section's 30-day payment rule to the provider's own assertions about claim submission and interest accrual, deeming payment due more than six years before suit and dismissing the action as time-barred.
Alleviation Med. Servs., P.C. v Hertz Co. (2015 NY Slip Op 50788(U)) Appellate Term, Second DepartmentApplies the section to deny the insurer's cross motion for summary judgment because it failed to establish timely denial, while leaving the denial of the provider's motion intact.
Alfa Med. Supplies v Utica Mut. Ins. Co. (2012 NY Slip Op 51890(U)) Appellate Term, Second DepartmentApplies the section's 30-day deadline to a denial issued more than 30 days after claim receipt, finding that the insurer proved no proper tolling and failed to establish that its defenses were not precluded.
BR Clinton Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51270(U)) Appellate Term, Second DepartmentApplies the section's 30-day period in denying the insurer's cross motion because it failed to prove timely mailing of verification requests, tolling or timely denials, and thus failed to show its IME nonappearance defense was not precluded.
Central Radiology Servs., P.C. v MVAIC (2010 NY Slip Op 50887(U)) Appellate Term, Second DepartmentApplies the section to hold that IME confirmation letters addressed to the insurer, with asserted carbon copies to the assignor, were not proper verification requests tolling the payment-or-denial deadline, precluding the insurer's IME nonappearance defense.
D.S. Chiropractic, P.C. v Country-Wide Ins. Co. (2009 NY Slip Op 51579(U)) Appellate Term, Second DepartmentApplies the section's 30-day determination period to reject the insurer's prematurity defense because verification follow-ups mailed on the 30th calendar day were premature and ineffective and therefore did not toll that period.
Radiology Today, P.C. v GEICO Ins. Co. (2009 NY Slip Op 51578(U)) Appellate Term, Second DepartmentApplies the section's 30-day determination period to hold that a premature verification follow-up mailed on the 30th calendar day failed to toll the deadline, making the denial untimely and precluding the medical-necessity defense.
Be Well Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 50346(U)) Appellate Term, Second DepartmentApplies the section to hold that a denial mailed 31 days after receipt of requested verification was untimely, precluding the medical-necessity defense and entitling the provider to summary judgment on that claim.
Elmont Open MRI & Diagnostic Radiology P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 50693(U)) Trial courtApplies the section's 30-day deadline in rejecting reliance on dated NF-10s kept in the insurer's file as proof of timely mailing, which is necessary to preserve its medical-necessity defense.
PDG Psychological P.C. v State Farm Mut. Ins. Co. (2005 NY Slip Op 50150(U)) Trial courtHolds that delay notices merely announcing pending verification results, without asking the provider to verify its claim, do not toll the section's 30-day payment-or-denial period.
Allstate Ins. Co. v Health E. Ambulatory Surgical Ctr. (2017 NY Slip Op 50574(U)) Trial courtApplies the section's rule deeming IME verification received on the examination date, finding the insurer's denial 28 days later untimely because a late verification request reduced the denial period to 25 days.
Chester Med. Diagnostic, P.C. v Kemper Cas. Ins. Co. (2008 NY Slip Op 52009(U)) Trial courtApplies the section's 30-day payment period to determine when benefits became overdue and the contract limitations period began, finding the provider's action timely despite the insurer's earlier denial.
Advantage Radiology, P.C. v ACE Am. Ins. Co. (2026 NY Slip Op 50245(U)) Trial courtApplies the section's 30-day rule to the workers' compensation coverage defense, denying dismissal because the insurer offered no evidence of a timely denial or verification request, despite a determination that the injuries were work related.
Lotus Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 23098) Trial courtReads the section together with the follow-up verification rule to measure the 10-day deadline for a follow-up EUO request from the missed appearance, rather than from expiration of the 30-day period for submitting documents, and adheres to provider summary judgment.
Matter of Interboro Mut. Indem. Ins. Co. (2009 NY Slip Op 29225) Trial courtGrants the insurer's request for a decretal paragraph providing that the failure to transmit denials under the section shall not apply to claims received or adjusted during its rehabilitation period.
LMK Psychological Servs., P.C. v Liberty Mut. Ins. Co. (2006 NY Slip Op 04486) Appellate Division, Third DepartmentCites the section for the 30-day payment-or-denial rule in explaining that a provider seeking summary judgment must prove mailing and receipt of claim forms and overdue payment.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 04260) Appellate Division, Second DepartmentCites the section in finding the insurer's defenses meritorious for purposes of vacating a default judgment and extending its time to answer.
A.M. Med., P.C. v Continental Ins. Co. (2015 NY Slip Op 50389(U)) Appellate Term, Second DepartmentRelies on the section's 30-day payment period to fix accrual of a no-fault cause of action at 30 days after claim receipt when applying the six-year contract statute of limitations.
Magnezit Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51434(U)) Appellate Term, Second DepartmentApplies the section's 30-day payment-or-denial period to preclude most defenses because the insurer failed to establish by competent evidence that it made timely verification requests tolling that period.
Sheepshead Bay Oral Surgery, PLLC v Unitrin Direct Ins. Co. (2019 NY Slip Op 51058(U)) Appellate Term, Second DepartmentCites the section for the rule that a first-party no-fault cause of action accrues 30 days after claim receipt in addressing the insurer's motion to dismiss on limitations grounds.
Metropolitan Radiological Imaging v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25063) Trial courtNotes that the insurers seeking discovery omitted the section's NF-10 denial forms and failed to explain how their demands related to timely denials or verification requests.
Socrates Psychological Servs., P.C. v Progressive Cas. Ins. Co. (2005 NY Slip Op 25096) Trial courtCites the section for the denial-of-claim form when ordering a deposition of the provider's managerial employee about mailing and receipt dates that may matter at trial.
Carnegie Hill Orthopedic Servs. P.C. v GEICO Ins. Co. (2008 NY Slip Op 50639(U)) Trial courtCites the section's 30-day payment rule in explaining defense preclusion for untimely denial and the narrow lack-of-coverage exception, while considering the insurer's contention that allegedly unnecessary or unperformed surgeries fell outside coverage.
Alev Med. Supply, Inc. v Progressive Ins. Co. (2010 NY Slip Op 50813(U)) Trial courtCites the section's 30-day payment-or-denial requirement as the basis for precluding most defenses absent a timely denial asserting them, in assessing discovery into equipment costs and alleged fraud.
First Stop P.T., P.C. v GEICO Ins. Co. (2025 NY Slip Op 50947(U)) Trial courtRelies on the section to explain that an insurer may await responses to timely verification requests and remains entitled to proper proof of claim, while later supplemental demands do not extend the denial deadline.
Mary Immaculate Hosp. Caritas Health Care v Government Employees Ins. Co. (2008 NY Slip Op 50638(U)) Trial courtApplies the section's 30-day rule to find the provider's prima facie case established where the insurer undisputedly neither paid nor denied, while recognizing a narrow exception to defense preclusion for lack of coverage.
Manhattan Med. Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 51844(U)) Trial courtCites the section, while recounting another decision, for the requirement to pay or deny within 30 days after receipt of proof of claim and the potential preclusion of defenses for noncompliance.
St. Paul Travelers Ins. Co. v Nandi (2007 NY Slip Op 51154(U)) Trial courtCites the section's requirement to pay or deny within 30 days after proof of the fact and amount of loss as background to the insurer's challenge to providers' eligibility for acupuncture reimbursement.
East Acupuncture, P.C. v Allstate Ins. Co. (2005 NY Slip Op 25242) Trial courtCites the section's definition of overdue benefits as unpaid 30 days after receipt of proof of claim, including requested verification, in a footnote accompanying its direction to calculate interest on settled claims.
Brownsville Advance Med., P.C. v Country-Wide Ins. Co. (2011 NY Slip Op 52255(U)) Trial courtCites the section's 30-day payment-or-denial deadline as background to the insurer's argument that unanswered verification requests made the provider's action premature.
Neomy Med., P.C. v American Tr. Ins. Co. (2011 NY Slip Op 50536(U)) Trial courtQuotes the section's 30-day payment-or-denial rule in discussing preclusion, then notes that timely disclaimer is unnecessary when the policy does not cover the incident giving rise to liability.
Hempstead Pain & Med. Servs., P.C. v General Assur. Co. (2006 NY Slip Op 26381) Trial courtNotes the provider's argument that the section compels payment when a late-submission denial omits the required advisory that reasonable justification may excuse the delay.
Prime Psychological Servs., P.C. v American Tr. Ins. Co. (2008 NY Slip Op 28273) Trial courtQuotes the section's requirement that denials be issued on the prescribed form in duplicate, framing the provider's challenge to the insurer's delivery of only one copy.
Unitrin Advantage Ins. Co. v Carothers (2007 NY Slip Op 52100(U)) Trial courtCites the section's 30-day payment-or-denial requirement as background to its consideration of whether a provider's failure to attend two EUOs supports the insurer's declaratory claim of noncooperation.
Allstate Social Work & Psychological Svcs PLLC v GEICO Gen. Ins. Co. (2005 NY Slip Op 50024(U)) Trial courtNotes the provider's argument that the section required payment or denial within 30 days of claim receipt, and its challenge to the insurer's proof that the denials were timely mailed.
Mega Supply & Billing, Inc. v American Tr. Ins. Co. (2005 NY Slip Op 51569(U)) Trial courtNotes the provider's argument under the section that the insurer failed to pay or deny within 30 days after receiving the claims.