Insufficient Denial

- “The defendant is required to either to pay or deny the plaintiff’s claims “within 30 calendar days after proof of claim [was] received.” 11 NYCRR 65-3.8(c) A proper denial of a claim must include the information called for in the prescribed denial of claim form (11 NYCRR 65-3.4[c][11]) and must “promptly apprise the claimant with a high degree of specificity of the ground or grounds on which the disclaimer is predicated” (General Acc. Ins. Group v. Cirucci, 46 N.Y.2d 862, 864, 387 N.E.2d 223, 414 N.Y.S.2d 512 [1979]; Accord Halali v. Evanston Ins. Co., 8 A.D.3d 431, 779 N.Y.S.2d 119; Hereford Ins. Co. v. Mohammod, 7 A.D.3d 490, 776 N.Y.S.2d 87). “An insurer which fail to properly deny a claim within the 30 days as required by these statutory provisions may be precluded form interposing a defense to the Plaintiff’s lawsuit”(Mount Sinai Hosp. v Triboro Coach, 236 A.D.2d 11, 16, 699 N.Y.S.2d 77; see e.g. Presbyterian Hosp. in City of NY v. Maryland Cas. Co., 90 N.Y.2d 274, 283, 683, N.E.2d 1, 660 N.Y.S.2d 536 [hereinafter Presbyterian I]; New York Hosp. Med. Ctr. of Queens v. Country-Wide Ins. Co., 295 A.D.2d 583, 584, 744 N.Y.S2d 201; New York and Presbyt. Hosp. v Empire Ins. Co. 286 A.D.2d 322, 728 N.Y.S.2d 684; Presbyterian Hosp. in City of N.Y. v. Maryland Cas. Co., 226 A.D.2d 613, 541 N.Y.S.2d 395 [hereinafter Presbyterian II]). Moreover, “[a] timely denial alone does not avoid preclusion where said denial is factually insufficient, conclusory, vague or otherwise involves a defense
which has no merit as a matter of law” (Amaze Med. Supply v. Allstate Ins. Co., 3 Misc 3d 43, 44 779 N.Y.S.2d 715)”. Nyack Hospital, etc. v. State Farm Mutual Automobile Insurance Company 11 A.D.3d 664; 784 N.Y.S.2d 136; 2004 N.Y. App. Div. Lexis 12514.

- “The defendant’s contention that it supplied the missing information, is without merit, as the defective claim could not be corrected, nunc pro tunc, through information supplied after the regulatory 30-day period expired. Indeed, the statutory goal of ensuring the prompt payment or denial of claims would be materially frustrated if insurance were permitted to file timely but factually defective denial of claim forms, to be supplemented only after the expiration of the 30-day period prescribed by 11 NYCRR 65-3.8“.Nyack Hospital, etc. v. State Farm Mutual Automobile Insurance Company 11 A.D.3d 664; 784 N.Y.S.2d 136; 2004 N.Y. App. Div. Lexis 12514.

- 11 NYCRR 65.15(g)(3)(i) clearly states that: “If the insurer denies a claim in whole or in part… the insurer shall notify the applicant.” The “applicant” is clearly identified in the top center of each bill submitted as: “OMNI Medical Services, P.C.” Omni’s Brooklyn address follows. Aniceto Gonzalez