July 7, 2014

Meridian Psychological Servs., PC v Government Empls. Ins. Co. (2014 NY Slip Op 24177)

https://www.beynensonlaw.com/case-law/meridian-psychological-servs-pc-v-government-empls-ins-co-2014-ny-slip-op-24177/

Court: District Court of Nassau County, First District
Judge: Hirsh, J.
Decided: July 7, 2014
Citation: 2014 NY Slip Op 24177 · 44 Misc 3d 650
Posture: Trial
Outcome: Provider prevailed
Issues: Verification requests Timeliness and preclusion
Legal questions: Outstanding verification and premature actions (see the maps)

Cite as

Meridian Psychological Servs., PC v Government Empls. Ins. Co., 44 Misc 3d 650 (Dist Ct, Nassau County, 1st Dist 2014)

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.

An insurer cannot continue to delay payment after receiving a completed but unsigned NF-2 without seeking further verification. The provider submitted signed claim and assignment forms, and the insurer requested a completed, signed no-fault application. After receiving an unsigned application, the insurer neither paid nor denied the claim nor sought further verification. On stipulated facts, the District Court, Nassau County, found for the provider. Under 11 NYCRR 65-3.5 (c) and 65-3.8 (a) (1), proper verification requests toll the payment period, but the insurer had to act upon the response. Even assuming its original request was timely, its failure to follow up under 11 NYCRR 65-3.6 (b) independently defeated its verification defense.

Reported in New York Official Reports at Meridian Psychological Servs., PC v Government Empls. Ins. Co. (2014 NY Slip Op 24177)

Meridian Psychological Servs., PC v Government Empls. Ins. Co.

2014 NY Slip Op 24177 [44 Misc 3d 650]

July 7, 2014

Hirsh, J.

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

As corrected through Wednesday, September 17, 2014

[*1]

Meridian Psychological Services, PC, as Assignee of Kenroy Palmer, Plaintiff,
v
Government Employees Insurance Co., Defendant.

District Court of Nassau County, First District, July 7, 2014

APPEARANCES OF COUNSEL

Israel, Israel & Purdy for plaintiff.

Printz & Goldstein for defendant.

{**44 Misc 3d at 650} OPINION OF THE COURT

Fred J. Hirsh, J.

Background

This matter was submitted to the court for decision on the following stipulated facts.{**44 Misc 3d at 651}

Kenroy Palmer was injured in a motor vehicle accident that occurred on August 16, 2010. On August 31, 2010 and September 2, 2010, Meridian Psychological Service, P.C. provided psychological services to Palmer for injuries sustained in the motor vehicle accident.

Meridian took an assignment of benefits and submitted the claim to Government Employees Insurance Co. (Geico) for payment.

Meridian mailed its claim for services, provided to Palmer on the aforementioned dates, to Geico on September 28, 2010. The documents sent to Geico included an NF-3, Verification of Treatment by Attending Physician or Other Provider of Health Services, signed by Walter Spear, Ph.D. on behalf of Meridian and an NF-AOB, New York Motor Vehicle No-Fault Insurance Law Assignment of Benefits Form signed by Palmer and Spear.

By letter dated October 17, 2010, Geico acknowledged receipt of Meridian’s claim and advised Meridian it would process the claim upon receipt of “A completed and signed no-fault application.”

By letter dated August 24, 2011, Meridian’s attorneys mailed a copy of a completed NF-2, “Application for Motor Vehicle No-Fault Benefits” that had not been [*2]signed by Palmer to Geico.

Geico did not respond to Meridian’s submission of the unsigned NF-2 or pay or deny the claim.

Meridian then commenced this action seeking to recover the unpaid no-fault benefits for the psychological services provided to Palmer.

Discussion

A carrier must pay or deny a claim for no-fault benefits within 30 days of receipt of a claim. (11 NYCRR 65-3.8 [a].)

A carrier’s time to pay or deny a no-fault claim is tolled or extended until it receives all timely and properly requested verification. (Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co., 44 AD3d 903 [2d Dept 2007]; 11 NYCRR 65-3.5 [c]; 65-3.8 [a] [1].) An insurer does not have to pay or deny a claim until it receives all timely requested verification. (St. Barnabas Hosp. v American Tr. Ins. Co., 57 AD3d 517 [2d Dept 2008]; Mount Sinai Hosp. v Chubb Group of Ins. Cos., 43 AD3d 889 [2d Dept 2007]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568 [2d Dept 2004]; 11 NYCRR 65-3.5 [c].){**44 Misc 3d at 652}

Geico could not continue to delay payment of Meridian’s claim after Geico received the completed but unsigned copy of the application for no-fault benefits from Meridian’s attorneys. (Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535 [2d Dept 2005]; Nyack Hosp. v Allstate Ins. Co., 13 Misc 3d 139[A], 2006 NY Slip Op 52233[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2006].) Upon receipt of the unsigned NF-2, Geico was required to either pay or deny the claim or requested additional verification. (Nyack Hosp. v Encompass Ins. Co.) Geico did neither.

Even if the court were to consider Geico’s October 17, 2010 letter a timely request for additional verification (11 NYCRR 65-3.5 [b]), Geico would not have a defense to this action because Geico did not comply with the follow-up verification requirements of the no-fault regulations. If a carrier requests additional verification and the additional verification is not received after 30 calendar days from the original request, the carrier must follow up with the party from whom additional verification was requested either by telephone or mail. (11 NYCRR 65-3.6 [b].) If the carrier fails to follow up on its request for additional verification, its time to pay or deny the claim is not extended. (Westchester Med. Ctr. v Allstate Ins. Co., 112 AD3d 916 [2d Dept 2013]; Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 106 AD3d 157 [2d Dept 2013].)

Since the parties stipulated to the timely submission of the claim, the psychological services provided by Meridian to Palmer are presumed to be necessary. (All County Open MRI & Diagn. Radiology P.C. v Travelers Ins. Co., 11 Misc 3d 131[A], 2006 NY Slip Op 50318[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2006].) Geico did not timely pay or deny the claim and/or did not properly or timely follow up on its request for additional verification. Therefore, Geico does not have a defense to this action.

The court finds for the plaintiff.

Legal questions

A question 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: Defense rejected because the insurer's requests or proof were deficient

Held the insurer had no verification defense because, after receiving the unsigned application, it neither paid, denied nor requested further verification, and in any event never followed up its initial request, so its time was not extended.

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, 82 (this one included) are in the same category.

Cited in this decision

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

Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 08038)The hospital's claim was premature because unrebutted proof showed that it ignored timely verification and follow-up requests.
St. Barnabas Hosp. v American Tr. Ins. Co. (2008 NY Slip Op 09585)The insurer raised a triable issue whether the provider timely complied with its verification demand, defeating the provider's summary judgment motion.
Mount Sinai Hosp. v Chubb Group of Ins. Cos. (2007 NY Slip Op 06650)The hospital's action was premature because it sued approximately two months before the insurer's time to pay or deny expired.
New York & Presbyt. Hosp. v Progressive Cas. Ins. Co. (2004 NY Slip Op 01750)The insurer proved policy exhaustion on one hospital claim and absence of coverage on another, requiring dismissal of both.
Nyack Hosp. v Encompass Ins. Co. (2005 NY Slip Op 08962) FollowedAn insurer's letters delaying payment pending its investigation do not toll the 30-day period for paying or denying a no-fault claim.
Nyack Hosp. v Allstate Ins. Co. (2006 NY Slip Op 52233(U))The insurer lacked a meritorious defense to vacate its default because a completed hospital facility form replaced the requested no-fault application.
Westchester Med. Ctr. v Allstate Ins. Co. (2013 NY Slip Op 08616) FollowedThe insurer failed to establish a verification toll because it offered no evidence of mailing a required follow-up request.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 02390) FollowedThe hospital's UB-04 form was not the functional equivalent of an NF-5 and did not support tolling before receipt of the NF-5.
All County Open MRI & Diagn. Radiology P.C. v Travelers Ins. Co. (2006 NY Slip Op 50318(U)) FollowedA peer review citing insufficient information cannot support denial without proof that the insurer sought that information through verification.

Similar decisions

PDG Psychological P.C. v State Farm Mut. Ins. Co. (2005 NY Slip Op 50150(U))The insurer's delay notices did not request verification, and its proof failed to establish mailing or fraud in the provider's claim.
New York & Presbyt. Hosp. v Government Empls. Ins. Co. (2005 NY Slip Op 02813)A hospital raised a triable issue whether the insurer's first verification request preceded submission of its claim.
Contemp. Med. Diag. & Treatment, P.C. v Government Employees Ins. Co. (2005 NY Slip Op 50254(U))The insurer's conclusory office-practice affidavit failed to prove timely mailing of verification requests.
Five Boro Psychological Servs., P.C. v AutoOne Ins. Co. (2008 NY Slip Op28510)The insurer's untimely initial verification request failed to toll the denial period, precluding its IME nonappearance defense.
Sea Side Med., P.C. v State Farm Mut. Auto Ins. Co. (2006 NY Slip Op 26246)A verification follow-up sent only 28 days after the initial request does not preserve the insurer's time to pay or deny a claim.