October 5, 2016

Compas Med., P.C. v Travelers Ins. Co. (2016 NY Slip Op 51441(U))

https://www.beynensonlaw.com/case-law/compas-med-p-c-v-travelers-ins-co-2016-ny-slip-op51441u/

Court: Appellate Term, Second Department
Decided: October 5, 2016
Citation: 2016 NY Slip Op 51441(U) · 53 Misc 3d 136(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Verification requests Timeliness and preclusion
Legal questions: Proof of mailing · Outstanding verification and premature actions (see the maps)

Cite as

Compas Med., P.C. v Travelers Ins. Co., 53 Misc 3d 136(A), 2016 NY Slip Op 51441(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016)

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 need not pay or deny a claim upon receiving only a partial response to its verification requests. The provider challenged summary judgment dismissing its claims for failure to supply requested verification. Under 11 NYCRR 65-3.8 (a) (1) and (b) (3), payment or denial was not required until all demanded verification was provided. The provider's objections to the requests were rejected because it neither alleged nor demonstrated that it had objected during claims processing. The insurer's proof established presumptive mailing of the initial and follow-up requests and nonreceipt of the requested verification. The Appellate Term, Second Department, affirmed the order granting the insurer summary judgment dismissing the complaint.

Reported in New York Official Reports at Compas Med., P.C. v Travelers Ins. Co. (2016 NY Slip Op 51441(U))

[*1]

Compas Med., P.C. v Travelers Ins. Co.

2016 NY Slip Op 51441(U) [53 Misc 3d 136(A)]

Decided on October 5, 2016

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This opinion is uncorrected and will not be published in the printed Official Reports.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 October 5, 2016

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2014-766 Q C

Compas Medical, P.C., as Assignee of KEVIN JACQUES, Appellant,
against
Travelers Insurance Company, Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Ulysses Bernard Leverett, J.), entered March 18, 2014. The order granted defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint on the ground that plaintiff had failed to provide requested verification.

Contrary to plaintiff’s contention, defendant was not required to pay or deny plaintiff’s claims upon receipt of a “partial response” to defendant’s verification requests (see 11 NYCRR 65-3.8 [a] [1]; [b] [3]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2004] [“A claim need not be paid or denied until all demanded verification is provided”]). To the extent that plaintiff asserts that certain of defendant’s requests were inappropriate, that argument also lacks merit, as plaintiff did not allege, much less demonstrate, that it objected to such requests during claims processing (see Rogy Med., P.C. v Clarendon Natl. Ins. Co., 43 Misc 3d 133[A], 2014 NY Slip Op 50629[U], *2 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014] [“inaction is an improper response to a verification request, and therefore plaintiff’s objections regarding the requests will not now be heard”]).

Contrary to plaintiff’s remaining contentions, the proof submitted by defendant in support of its motion was sufficient to give rise to a presumption that the initial and follow-up verification requests had been properly mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), and to demonstrate that defendant had not received the requested verification.

Accordingly, the order is affirmed.

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

Decision Date: October 05, 2016

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.

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

Held the insurer's proof sufficient to raise a presumption that its initial and follow-up verification requests were properly mailed, rejecting the provider's contentions.

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.

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 the insurer need not pay or deny on a partial response, the provider's unraised objections to the requests could not be heard, and the requests were properly mailed and unanswered, so dismissal was affirmed.

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. One decision in other departments that cites or is cited by this one is on the full map.

Cited in this decision

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

New York & Presbyt. Hosp. v Progressive Cas. Ins. Co. (2004 NY Slip Op 01750) FollowedThe insurer proved policy exhaustion on one hospital claim and absence of coverage on another, requiring dismissal of both.
Rogy Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 50629(U)) FollowedThe insurer established lack of medical necessity for three claims and outstanding verification for two, but failed on two others.
St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.

Cited by

A label shows how the later decision treated this one.

Lenox Hill Radiology & MIA, P.C. v Hereford Ins. Co. (2021 NY Slip Op 21157) FollowedA provider may not condition compliance with an MRI-film verification request on advance payment of reproduction costs.
Chapa Prods. Corp. v MVAIC (2019 NY Slip Op 29341)An insurer must deny a claim for failure to provide verification within 30 days after the 120-day response period expires.
American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U))A provider's substantial compliance with reasonable additional verification requests does not make its claims payable.

Similar decisions

Compas Med., P.C. v American Tr. Ins. Co. (2015 NY Slip Op 51240(U))Conflicting proof of claim receipt and verification responses precluded summary judgment for either party.
Compas Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51417(U))The insurer established proper mailing of verification requests and denials and timely denial after receipt of verification.
Compas Med., P.C. v Travelers Insurance Company (2016 NY Slip Op 51424(U))The insurer proved a verification defense to one claim but lacked personal-knowledge proof of EUO nonappearance for seven others.
New Horizon Surgical Ctr., LLC v Travelers Ins. Co. (2019 NY Slip Op 51690(U))An insurer need not pay or deny a claim upon receiving only a partial response to its verification requests.
Compas Med., P.C. v Farmington Cas. Co. (2016 NY Slip Op 50925(U))The insurer established outstanding verification for one claim and timely mailing of IME nonappearance denials for the remaining claims.