May 18, 2015

Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50773(U))

Headnote

The main issue in this case was whether the insurance company was entitled to summary judgment dismissing the portion of a claim for first-party no-fault benefits that was billed under code 97810, based on the provider's failure to respond to the insurer's verification requests. The court considered the fact that the single claim form involved two types of services, each billed under a separate code, and found that the insurer had established its defense as to one code, but not as to code 97810. The court held that a claim need not be paid or denied until all demanded verification is provided, and that a timely verification request tolls an insurer's time to pay or deny the entire claim. The insurer demonstrated that it had timely mailed initial and follow-up requests for verification and had not received the requested verification, so the court reversed the lower court's decision and granted the insurer's motion for summary judgment dismissing the claim billed under code 97810.

Reported in New York Official Reports at Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50773(U))

Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 50773(U)) [*1]

Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co.

2015 NY Slip Op 50773(U) [47 Misc 3d 149(A)]

Decided on May 18, 2015

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on May 18, 2015

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-2450 Q C

Healthy Way Acupuncture, P.C. as Assignee of LAZARA ESTRADA, Respondent,
against
Ny Central Mutual Fire Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Joseph E. Capella, J.), entered October 9, 2012. The order, insofar as appealed from, denied the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of a claim that was billed under code 97810.

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of a claim that was billed under code 97810 is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment on the single claim form that was the basis of the complaint, alleging that plaintiff had failed to respond to defendant’s verification requests. The single claim form involved two types of services, each of which was billed under a separate code. The Civil Court found that defendant had established its defense as to one code, but not as to code 97810. Defendant appeals from so much of the order as denied the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of the claim that was billed under code 97810.

Since a claim need not be paid or denied until all demanded verification with respect thereto is provided (see Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553, 554 [1999]), a timely verification request tolls an insurer’s time to pay or deny the entire claim. Thus, any action to recover payment on that claim is premature when the provider has failed to respond to a request for verification (see Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492, 493 [2005]). In support of its motion, defendant demonstrated that it had timely mailed initial and follow-up requests for verification (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]) and that it had not received the requested verification.

Accordingly, the order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking summary judgment dismissing so much the complaint as sought to recover upon the portion of the claim that was billed under code 97810 is granted.

Pesce, P.J., Aliotta and Solomon, JJ., concur.

Decision Date: May 18, 2015