Sunday, June 21, 2009

Verifications Requests

- The insurer shall not issue a denial prior to the receipt of verification of all the relevant information. Section 5-3.5.

- Once the insurer issues a denial of a proof of claim, it waives its right to other requested verification if it’s still outstanding. By serving its denial, the insurer in fact affirms the fact that it has all of the relevant information it deems necessary to serve a denial. See 11NYCRR Section 65-3.8(a)(1); (c) and Exclusive Medical & Diagnostic, P.C. v. New York Central Mutual Fire Ins. Co., N.Y.L.J., March 30, 2004, Special Term Pt. 1, p. 43 col. 3.

- It is a respondent’s burden to establish the reasonableness of the verification requests. The conditions form the 11 NYCRR §65-1, (stating that “The eligible injured person shall submit to medical examination by physicals selected by, or acceptable to the Company when and as often as, the company may reasonable require.”), doesn’t give the insurer the right to conduct an Examination without first establishing reasonable grounds. In other words, it’s respondents burden to establish the reasonableness of the verification requests. Assessment Number: 179913519404, File No.: 11190

- To deny coverage based upon the missed appointment, without affording the claimant the opportunity to appear for a rescheduled examination is unreasonable and fails to comply with 11 NYCRR §65-15. Assessment Number: 179913519404, File No.: 11190

- A request for a medical examination constitutes a verification of the claim and if a necessary verification is not complied with, then within 30 days after said request, a follow up request will be made. 11 NYCRR §65-15. Assessment Number: 179913519404, File No.: 11190

- Even if the IME requests were sent before insurer received the bills as a condition precedent to the bringing of claim, the insurer has to follow all the requirements pursuant to the Opinion of the Office of General Counsel of New York State Insurance Department, clearly states that “… an insurer’s request for an IME of an Eligible Injured Person prior to the receipt of a claim is a verification request which requires the insurer afford a second opportunity for the person to appear under the applicable follow-up procedures contained in Section 65-3.6(b).”

- “Within 10 business days of receipt” of a No-Fault claim, under the old regulations, or “within 15 business days of receipt” under the new regulations, an insurer may seek additional verification of claim, 11 NYCRR §65.15[d][2]; Mount Sinai Hospital v. Triboro Coach, 263 A.D.2d 11, 699 N.Y.S. 2d 77 (2nd Dept. 1999); 11NYCRR §65-3.5 (b), thereby delaying the statutory 30-day period in which to pay or deny, Presbyterian Hosp. in City of N.Y. v. Maryland Cas. Co., 90 N.Y.2d. at 280-81; New York Hosp. Med. Ctr. of Queens v. Country-Wide Ins. Co., 295 A.D.2d. at 578; Mount Sinai Hosp. v. Triboro Coach, 263 A.D.2d at 16.

- If the requested verification is not received within 30 days, the insurance company, within 10 days of the insured’s failure to respond, must “follow up with the party form whom the verification was originally requested, either by a telephone call properly documented in the file, or by mail.” 11 NYCRR §65.15(e); New York & Presbyterian Hospital, et al., v. Progressive Casualty Insurance Company, 2004 N.Y. App. Div. LEXIS 2658 (2nd Dept.)

- An examiner is not permitted to deny a claim within the pendency of a verification request. Insurance companies are held to a strict adherence of the timing mechanism for verification and denials set forth in the regulations. Kings Medical Supply Inc. v. Travelers Prop. Cas. Corp., 194 Misc.2d 667, 2003 N.Y. Misc. LEXIS 35 (N.Y. Misc. January 14, 2003, Decided).

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