Appellate Term, First Department
Nov 21, 2014
2014 NY Slip Op 51645(U)
Provider prevailed
MVAIC failed to prove late claim submission because its representative's conclusory assertion of unawareness did not establish nonreceipt. The representative stated that MVAIC was unaware of the provider's bills before suit, but did not indicate that anyone searched the assignor's file to determine whether the claims had been logged as received. That showing did not establish submission beyond the 45-day limit under 11 NYCRR 65-1.1 (d), regardless of the provider's opposition. The Appellate Term, First Department, modified the order to deny MVAIC's summary judgment motion and reinstate the complaint. It also granted the provider's discovery cross motion to the extent of directing answers to three interrogatories materially relevant to MVAIC's receipt of the claims.
Appellate Term, First Department
Nov 3, 2014
2014 NY Slip Op 51569(U)
Provider prevailed
The insurer failed to raise a medical necessity issue because it submitted neither the IME report supporting its denial nor other evidence. The providers established entitlement to summary judgment by showing that the necessary billing documents were mailed to and received by the insurer and that payment was overdue under Insurance Law § 5106 (a) and 11 NYCRR 65-3.8 (a) (1). Although the insurer demonstrated a timely medical necessity denial, it supplied no evidentiary proof supporting that defense. Without evidentiary facts establishing a bona fide dispute over the necessity of the services, the providers were entitled to judgment. The Appellate Term, First Department, affirmed the appealed grant of their cross motion for summary judgment.
Trial court, First Department
Nov 17, 2014
2014 NY Slip Op 24362
Insurer prevailed
An insurer complies with 11 NYCRR 68.6 by paying the applicable local fee-schedule amount for services rendered outside New York. The Civil Court, Bronx County, granted the insurer's motion to dismiss and denied the provider's summary judgment cross motion concerning surgery performed in New Jersey. Relying on Insurance Law § 5108, 11 NYCRR 68.5 (b), administrative interpretation and cost-containment goals, it treated the local schedule as the permissible charge. Verification tolled the denial period, and the denial issued within 30 days after the provider supplied the requested information. The denial form preserved the fee-schedule defense. Under 11 NYCRR 65-3.8 (d), partial payment did not waive that defense. The court also considered a reply affidavit because the provider had an opportunity to respond.
Trial court, Second Department
Nov 10, 2014
2014 NY Slip Op 51594(U)
Provider prevailed
⚠ Not followed by Country-Wide Ins. Co. v Yao Jian Ping (2024 NY Slip Op 24033)
An insurer's denial of all future no-fault benefits based on an IME excuses timely submission of later treatment claims. The insurer sought summary judgment under 11 NYCRR 65-1.1, asserting that it never received the provider's bill for physical therapy rendered after the benefits cutoff. The provider offered no proof of mailing but argued that the insurer's repudiation excused submission. The District Court, Nassau County, denied the insurer's motion, following Matter of State Farm Ins. Co. v Domotor. Although a later Insurance Department opinion required continued claim submission after a prospective denial, the court considered itself bound by Second Department precedent. The provider could pursue its claim despite failing to submit the claim form timely.
