Appellate Term, Second Department
Oct 21, 2003
2003 NY Slip Op 51392(U)
Provider prevailed
An EUO request does not toll the 30-day payment-or-denial period under the no-fault regulation governing services rendered in 2001. The Appellate Term, Second Department, reversed the denial of the provider's summary judgment motion and granted judgment for all claims. Two claims were neither paid nor denied. Two others were untimely denied because 11 NYCRR 65.12 required medical examinations but did not require EUOs; that requirement appeared the following year in 11 NYCRR 65-3.5 (e). For two claims the insurer denied receiving, the billing manager's affidavit of mailing and postmarked receipt supported recovery. The matter was remanded to calculate interest and attorney fees under Insurance Law § 5106 (a), 11 NYCRR 65-3.9 (a), and 11 NYCRR 65-3.10 (a).
Appellate Term, Second Department
Oct 21, 2003
2003 NY Slip Op 51405(U)
Provider prevailed
The insurer failed to establish a reasonable excuse for its late answer or a meritorious defense. The Appellate Term, Second Department, reversed the order compelling the provider to accept the answer and denied the insurer's motion. Under CPLR 3012 (d), the insurer needed both an adequate excuse and a meritorious defense. Counsel attributed the delay to the home office's failure to forward the summons and complaint promptly, but lacked personal knowledge of receipt and forwarding dates. A purported extension stipulation was unsigned by provider's counsel, who denied agreeing to any extension, and therefore was not binding. Defense counsel also failed to attach an affidavit of merit.
Appellate Term, Second Department
Oct 21, 2003
2003 NY Slip Op 51393(U)
Provider prevailed
An assignor's EUO nonappearance does not support denial under the no-fault regulation governing services rendered in 2001. The Appellate Term, Second Department, reversed the denial of the provider's summary judgment motion and granted judgment for all claims. Four claims were denied late. Claims denied for EUO nonappearance were also payable because 11 NYCRR 65.12 required medical examinations but contained no EUO requirement; the insurer's EUO request therefore did not toll the 30-day payment-or-denial period. For two bills the insurer denied receiving, the billing manager supplied an affidavit of mailing and a postmarked receipt. The court remanded for calculation of interest and attorney fees under Insurance Law § 5106 (a), 11 NYCRR 65-3.9 (a), and 11 NYCRR 65-3.10 (a).
Appellate Term, Second Department
Oct 21, 2003
2003 NY Slip Op 51579(U)
Insurer prevailed
The provider's failure to answer valid, timely verification requests defeated summary judgment based on the insurer's delayed denials. The provider sought no-fault benefits for two assignors, arguing that the insurer failed to pay or deny within 30 days under Insurance Law § 5106 (a). The Appellate Term, Second Department, affirmed denial of the provider's motion. Under 11 NYCRR 65.15 (d) and (g), the unanswered requests rebutted the prima facie showing made through claim forms by demonstrating that completed proof of claim had not been supplied. The insurer's opposition also raised a factual issue concerning fraud as to one assignor's portion of the claim.
