Sunday, June 21, 2009

Defective Denial

- The denial of claim is “fatally defective” when it failed to include the information listed in items 23 though 30 of the prescribed denial form (including the name of the provider, the date and amount of the claims being denied, and the date it received those claims), and when the defects in the denial were not cured by supplying the previously-omitted information before the expiration of the 30-day statutory period. Nyack Hosp. v. State Farm Mut. Auto. Ins. Co., 2004 WL 2394038, 2004 NY Slip Op 07663 (2d Dept. October 25, 2004)

- A valid denial of claim must include the information called for in the prescribed denial of claim form, 11NYCRR §65-3.4(c)(11), and must “promptly apprise the claimant with a high degree of specificity of the grounds on which the disclaimer is predicated”. General Accident Ins. Group v. Cirucci, 46 NY2d 862, 864, 414 NYSd512, 387 NY2d 223 (1979)

- Assuming arguendo that the denial is valid, however, “(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 (Regnoso) v. Allstate Ins. Co., 2004 NY Slip Op 24119 (App Term 2d Dept. 2004).

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