April 12, 2019

CPM Med Supply, Inc. v State Farm Fire & Cas. Ins. Co. (2019 NY Slip Op 50576(U))

https://www.beynensonlaw.com/case-law/cpm-med-supply-inc-v-state-farm-fire-cas-ins-co-2019-ny-slip-op50576u/

Court: Appellate Term, Second Department
Decided: April 12, 2019
Citation: 2019 NY Slip Op 50576(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 3 later decisions (see Cited by)
Issues: Verification requests
Legal questions: Outstanding verification and premature actions (see the maps)

Cite as

CPM Med Supply, Inc. v State Farm Fire & Cas. Ins. Co., 2019 NY Slip Op 50576(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2019)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

A provider's opinion that requested invoices are unnecessary does not reasonably justify failing to supply verification. The provider did not respond to verification requests for one claim. For another, it asserted that invoices were unnecessary under its interpretation of reimbursement rules, but neither supplied them nor stated that they were outside its possession or control. That response was insufficient under 11 NYCRR 65-3.8 (b) (3). The insurer properly denied both claims after 120 days without the requested verification under 11 NYCRR 65-3.5 (o) and 65-3.8 (b) (3). Although dismissal with prejudice was warranted, the Appellate Term, Second Department, affirmed dismissal as premature because the insurer had not cross-appealed.

Reported in New York Official Reports at CPM Med Supply, Inc. v State Farm Fire & Cas. Ins. Co. (2019 NY Slip Op 50576(U))

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

CPM Med Supply, Inc., as Assignee of Carlos Espinoza-Calle, Appellant,
against
State Farm Fire and Casualty Insurance Company, Respondent.

Fuld & Karp, P.C. (David Karp of counsel), for appellant. Richard T. Lau & Associates (Linda Filosa and Arthur Kontaxis of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Richard J. Montelione, J.), entered August 31, 2016. The order granted defendant’s motion for summary judgment dismissing the complaint as premature.

ORDERED that the order is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint as premature, as plaintiff had failed to provide verification which defendant had requested.

Contrary to plaintiff’s argument, it was required to respond to defendant’s verification requests. As plaintiff did not respond to defendant’s verification requests with respect to plaintiff’s claim for the sum of $1,989.85, plaintiff failed to demonstrate a basis to disturb so much of the order as dismissed the complaint insofar as it sought to recover upon the $1,989.85 claim.

While plaintiff did respond in writing to defendant’s verification requests pertaining to the claim for $1,785, plaintiff neither provided the invoices requested by defendant nor stated that it was not in possession or control of those invoices. Rather, plaintiff merely set forth its opinion that the items requested were “not needed,” based upon its own interpretation of how the rate of reimbursement should be calculated. This is not a “reasonable justification for the failure to comply” with a verification request (11 NYCRR 65-3.8 [b] [3]), or a sufficient response (see Village Med. Supply, Inc. v Travelers Prop. Cas. Ins. Co., 61 Misc 3d 126[A], 2018 NY Slip Op 51311[U] [App Term, 1st Dept 2018]; D & R Med. Supply v American Tr. Ins. Co., 32 Misc 3d 144[A], 2011 NY Slip Op 51727[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]; Urban Radiology, P.C. v Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010]; cf. Mount Sinai Hosp. v Auto One Ins. Co., 121 AD3d 869 [2014]).

We note that while the Civil Court dismissed the complaint as premature, the claimed services were rendered after April 1, 2013, and defendant properly denied the claims at issue on the ground that plaintiff had failed to provide the requested verification within 120 days of the initial verification request in this action (see 11 NYCRR 65-3.5 [o]; 65-3.8 [b] [3]). Therefore, defendant was entitled to dismissal of plaintiff’s complaint with prejudice, but as defendant has not cross-appealed, the order is affirmed.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.

ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 12, 2019

Legal questions

A question of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.

Outstanding verification and premature actions

Open the full map

Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?

This decision: Insurer properly denied the claim because verification was not provided (120-day rule)

Held the provider's failure to respond, and its written reply that requested invoices were 'not needed,' insufficient, and stated that the insurer properly denied post-2013 claims for nonresponse within 120 days and was entitled to dismissal with prejudice.

Premature: verification outstandingNonresponse denial upheldTriable issueInsurer's showing failsProvider compliedThis decisionCites it or cited by itCited or followedDistinguished or limited

Of the 374 decisions on this question in the Second Department courts and the Court of Appeals, 22 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Cited in this decision

A label shows how this decision treated the case it cites.

Village Med. Supply, Inc. v Travelers Prop. Cas. Ins. Co. (2018 NY Slip Op 51311(U)) FollowedThe provider's claims were premature because it failed to answer verification requests for a manufacturer's invoice.
D & R Med. Supply v American Tr. Ins. Co. (2011 NY Slip Op 51727(U)) FollowedThe provider's incomplete verification responses left the insurer's time to pay or deny untriggered and the action premature.
Urban Radiology, P.C. v Tri-State Consumer Ins. Co. (2010 NY Slip Op 50987(U)) FollowedThe insurer established premature claims for unanswered verification and lack of medical necessity for the remaining claims.
Mount Sinai Hosp. v Auto One Ins. Co. (2014 NYSlipOp 06954) Contrasted (cf., but see)The insurer failed to establish prematurity because the hospital responded to verification and the requests' propriety remained disputed.

Cited by

A label shows how the later decision treated this one.

Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 50623(U)) FollowedThe provider's qualified assertion of mailing verification failed to show compliance or a reasonable justification for noncompliance.
Remedy Chiropractic, P.C. v Nationwide Ins. (2022 NY Slip Op 50935(U)) FollowedThe provider failed to raise a factual issue that it supplied outstanding verification or reasonably justified withholding it.
American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U)) FollowedA provider's substantial compliance with reasonable additional verification requests does not make its claims payable.
Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2023 NY Slip Op 50794(U))The provider failed to show that it supplied requested verification or reasonably justified noncompliance.
Veraso Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 50583(U))The insurer's motion for summary judgment dismissing the provider's complaint was granted, and the provider's cross motion was denied.
Veraso Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 50584(U))The insurer's motion for summary judgment dismissing the provider's complaint was granted, and the provider's cross motion was denied.
Veraso Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2022 NY Slip Op 51232(U))The trial record supported findings that the provider had not fully supplied requested verification and that the insurer timely denied the claim.
New York Manual, P.T., P.C. v Nationwide Affinity Ins. Co. of Am. (2023 NY Slip Op 50281(U))The provider failed to raise a triable issue that it supplied requested verification or reasonably justified noncompliance.

Similar decisions

Active Care Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51408(U))The provider's opposing affidavit raised a triable issue as to whether its action was premature for outstanding verification.
JCC Med., P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51140(U))The provider's affidavit raised a factual issue over receipt of requested verification and whether the second cause of action was premature.
T & S Med. Supply Corp. v New York Cent. Mut. Fire Ins. Co. (2017 NY Slip Op 51453(U))The provider's affidavit raised a triable issue as to whether it had supplied the requested verification.
Right Aid Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51857(U))The provider's mailing affidavit raised a triable issue as to whether its action was premature for failure to supply verification.
New Way Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 50925(U))The provider's action was premature because it had not supplied the insurer's requested verification, including wholesale equipment invoices.