St. Barnabas Hospital, a/a/o DAWN HENRY v. Government Employees Insurance Company, 47 N.Y.S.3d 865, 2017 N.Y. Slip Op. 27056


At issue is whether the insurer timely and properly requested additional verification from the Plaintiff hospital upon its receipt of proof of the claim which effectively tolls the 30-day time period. The billing was sent via certified mail, return receipt requested, and was received by the insurer.  The insurer then served a request for additional verification. Hospital  served a response letter acknowledging receipt of the insurer’s request wherein it objected to the validity of the request.  The insurer served a second follow-up request for additional verification.  Hospital never responded.  The Court stated as follows:


The Plaintiff has failed to establish a prima facie showing that it is entitled to judgment as a matter of law on its claim to recover no-fault medical payments. The Plaintiff’s claim is premature as the evidence presented demonstrates that the thirty 30-day time period within which an insurer must pay or deny a claim has not been triggered. In turn, the Plaintiff failed to sufficiently respond to the Defendant’s requests for additional verification.

The Plaintiff’s position that the verification request was improper because it is not required under the insurance regulations or no fault law is without merit. The Defendant, GEICO, referenced Circular Letter No. 4 dated January 12, 2011, issued by the State of New York Insurance Department, in its original request for additional verification. The purpose of the Circular Letter is to advise no-fault insurers and health insurers of the amendment of Insurance Law §5103(b)(2) and to interpret the regulations related thereto. While the Plaintiff concedes that the law was amended in January 2011 to reflect that insurers are prohibited from excluding from coverage necessary emergency health services even where the patient was intoxicated by alcohol or drugs, the Plaintiff fails to address the portion of the Circular Letter at issue here. Specifically, the Plaintiff submits no argument or opposition with regard to the portion of the Circular Letter that permits a no-fault insurer to request a hospital to specify what portion of the bill consists of “necessary emergency health services”. Rather, the Plaintiff claims that the statutory language does not explicitly provide as such. The Court disagrees. 11 NYCRR 65-3.5(c) provides that “[t]he insurer is entitled to *4 receive all items necessary to verify the claim directly from the parties from whom such verification was requested.”

The Court also disagrees with the Plaintiff’s contention that it fully responded to the Defendant’s verification requests by merely stating, “[t]he patient received ‘Necessary Emergency Health Services’ during his admission at the hospital.” The Plaintiff’s response is vague in that it fails to delineate whether some, most or all of the services were in fact “necessary emergency health services”. Further, in its Circular Letter, the Insurance Department contemplated the need for hospitals to specify what portion of the bill consists of such emergency services. The Insurance Department also defined “necessary emergency health services” as sudden pain or injury that is treated until the patient is stabilized, generally in the emergency room.

In the matter sub judice, the patient was admitted to St. Barnabas for approximately three (3) days from April 10, 2016 through April 13, 2016. The Defendant, GEICO, submitted sufficient proof in admissible form showing that the patient was intoxicated by alcohol and Marijuana at the time of the accident. As such, GEICO was entitled to request information concerning the breakdown of services until the patient was found to be stabilized in accordance with the Insurance Law §5103(b)(2), as amended, and the related Circular Letter No. 4 interpreting the statute. Such information would permit GEICO to assess when the no-fault insurance coverage ceases, if at all, and the appropriate amount of the claim that must be paid.

Pursuant to 11 NYCRR 65-3.6(b), where there is a timely original request for verification, but no response to the request for verification is received within 30 calendar days thereafter, or the response to the original request for verification is incomplete, then the insurer, within 10 calendar days after the expiration of that 30-day period, must follow up with a second request for verification. When a no-fault medical service provider fails to respond or inadequately responds to two timely verification requests, the 30 days in which to pay or deny the claim is tolled and does not begin to run. Accordingly, any claim for payment by the medical service provider after two timely requests for verification is premature (See Sound Shore Med. Ctr. V. New York Cent. Mut. Fire Ins. Co., 963 N.Y.S.2d 282 [2d Dept. 2013].

Thus, as the Defendant correctly maintains, the Plaintiff’s initial claim for payment was premature and was not complete until the Defendant received additional verification of the claim as requested (See 11 NYCRR 65-3.8(a)(1), (b)(3); Nyack Hosp. v. State Farm Mut. Auto. Ins. Co., 19 AD3d 569 [2d Dept. 2005]).

Where, as here, the insurer presents sufficient evidence that it timely requested additional verification and the hospital fails to provide the information requested, the complaint must be dismissed as premature (St. Vincent’s Hosp. of Richmond v. American Transit Ins. Co.. 299 AD2d 338 [2d Dept. 2002]).

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