May 18, 2015

Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50773(U))

https://www.beynensonlaw.com/case-law/healthy-way-acupuncture-p-c-v-ny-cent-mut-fire-ins-co-2015-ny-slipop-50773u/

Court: Appellate Term, Second Department
Decided: May 18, 2015
Citation: 2015 NY Slip Op 50773(U) · 47 Misc 3d 149(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Verification requests
Legal questions: Outstanding verification and premature actions · Proof of mailing (see the maps)

Cite as

Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co., 47 Misc 3d 149(A), 2015 NY Slip Op 50773(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

A timely verification request tolls the insurer's time to pay or deny the entire claim, even when the claim bills services under separate codes. The provider's single claim form billed two types of services, and Civil Court, Queens County, accepted the insurer's verification defense for one code but denied dismissal for code 97810. The insurer demonstrated timely mailing of initial and follow-up verification requests and nonreceipt of the requested verification. Because the claim need not be paid or denied until all demanded verification was supplied, the action was premature as to the remaining portion too. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted summary judgment dismissing the portion billed under code 97810.

Reported in New York Official Reports at Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50773(U))

[*1]

Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co.

2015 NY Slip Op 50773(U) [47 Misc 3d 149(A)]

Decided on May 18, 2015

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on May 18, 2015

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-2450 Q C

Healthy Way Acupuncture, P.C. as Assignee of LAZARA ESTRADA, Respondent,
against
Ny Central Mutual Fire Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Joseph E. Capella, J.), entered October 9, 2012. The order, insofar as appealed from, denied the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of a claim that was billed under code 97810.

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of a claim that was billed under code 97810 is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment on the single claim form that was the basis of the complaint, alleging that plaintiff had failed to respond to defendant’s verification requests. The single claim form involved two types of services, each of which was billed under a separate code. The Civil Court found that defendant had established its defense as to one code, but not as to code 97810. Defendant appeals from so much of the order as denied the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of the claim that was billed under code 97810.

Since a claim need not be paid or denied until all demanded verification with respect thereto is provided (see Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553, 554 [1999]), a timely verification request tolls an insurer’s time to pay or deny the entire claim. Thus, any action to recover payment on that claim is premature when the provider has failed to respond to a request for verification (see Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492, 493 [2005]). In support of its motion, defendant demonstrated that it had timely mailed initial and follow-up requests for verification (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]) and that it had not received the requested verification.

Accordingly, the order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of the claim that was billed under code 97810 is granted.

Pesce, P.J., Aliotta and Solomon, JJ., concur.

Decision Date: May 18, 2015

Legal questions (2)

Questions of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.

Outstanding verification and premature actions

Open the full map

Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?

This decision: Timely requests went unanswered; the claim is not overdue and the action is premature

Held a timely verification request tolls the time to pay or deny the entire claim form, so the unanswered requests made the action premature as to the portion billed under the second code too.

Premature: verification outstandingNonresponse denial upheldTriable issueInsurer's showing failsProvider compliedThis decisionCites it or cited by itCited or followed

Of the 385 decisions on this question in the Second Department courts and the Court of Appeals, 153 (this one included) are in the same category.

Proof of mailing

Open the full map

Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)

Held the insurer demonstrated timely mailing of its initial and follow-up verification requests.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 09484) FollowedAn insurer need not pay or deny a no-fault claim until it receives all relevant verification requested.
St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)The insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345)An insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.

Similar decisions

New Way Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 51706(U))Letters merely delaying payment without requesting specific verification do not toll the insurer's time to pay or deny a claim.
Healthy Way Acupuncture, P.C. v Farmington Cas. Co. (2015 NY Slip Op 51595(U))Neither party established entitlement to summary judgment: the insurer's mailing proof and the provider's supporting affirmation were deficient.
Boai Zhong Yi Acupuncture Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51202(U))The insurer established timely mailing of verification requests, tolling the 30-day period and making its denials timely.
Northshore Chiropractic Diagnostics, P.C. v A. Cent. Ins. Co. (2014 NY Slip Op 51825(U))The insurer's verification requests were timely, but a factual issue remained as to whether the provider adequately responded.
Lefferts Gardens Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2022 NY Slip Op 50599(U))The provider's action was premature because it failed to respond to the insurer's timely and proper verification requests.