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Verify. . . Verify. . .Verify
By: Charles W. Benton, Esq.

FOR THE DEFENSE

Verify. . . Verify. . .Verify

By: Charles W. Benton, Esq.
Bruno, Gerbino & Soriano, LLP
Melville, New York


Some insurance carriers make no-fault verification requests a standard office practice when faced with claim submissions from medical providers which lack pertinent information. Some carriers leave verification requests to the discretion of the claims rep on an ad hoc basis. Some insurance providers only use verification requests sporadically; other use them so infrequently that they effectively don’t utilize them at all.

The recent Appellate Division, Second Department case of Central Suffolk Hospital/Legette v. New York Central Mutual Fire Insurance Company, A.D.3d , 2005 N.Y. Slip Op 9484 (December 12, 2005), shows how properly imposed verification requests can form the basis of successful defenses when an insurance company is sued by a medical provider for non-payment of no-fault claims.

Central Suffolk Hospital involved two bundled and different sets of no-fault claims. The lower court, Supreme Court, Nassau County, denied that branch of plaintiffs’ motion which sought summary judgment on the first cause of action, and the plaintiffs appealed from that determination. The defendant New York Central Mutual cross-appealed from so much of that same order which denied its cross-motion for summary judgment dismissing the complaint.

The Appellate Division in Central Suffolk found that the lower court had improperly denied defendant’s summary judgment cross-motion with regard to the first cause of action to recover payments for medical services provided by Central Suffolk Hospital. The Appellate Division found that New York Central Mutual had made a prima facie showing in the lower court that it was entitled to summary judgment. In response to that showing, Central Suffolk Hospital admitted receiving the defendant’s initial request for verification, yet failed to state what response, if any, it made to that request. Under 11 NYCRR 65.15[g] and [i], an insurer is not obligated to pay or deny a claim until it has received verification of all relevant information requested. Thus, the Appellate Division found that New York Central Mutual was entitled to summary judgment pursuant to 11 NYCRR 65-3.8(a)(1) and (b)(3) dismissing the first cause of action.


With regard to the second cause of action by White Plains Hospital Center, the Appellate Division in Central Suffolk also found that the lower court improperly denied New York Central Mutual’s cross-motion for summary judgment on that claim. The principal amount of the second claim had been paid, leaving only that portion of the second cause of action seeking interest and an award of an attorney’s fee. White Plains maintained that it did not receive verification requests which New York Central Mutual asserted were sent by mail to it. White Plains, however, did provide verification of the claim pursuant to New York Central Mutual’s request. The Appellate Division found that, in view of this circumstance, the assertion that the claim underlying the second cause of action was not timely paid, the predicate for the plaintiffs’ claim for interest and an attorney’s fee award, was without basis under 11 NYCRR 65-3.8.

The moral of this story? Verification requests by an insurance carrier are not only legitimate tools for eliciting information regarding no-fault claims; they may also form the basis of successful defenses regarding future no-fault lawsuits. Insurance carriers not currently utilizing verification requests on a regular basis thus may want to rethink their strategy in this regard.

Editors Note: Charles W. Benton is a graduate of Fordham University School of Law and an associate of the Appeals Division at Bruno, Gerbino & Soriano, LLP, located in Melville, New York.

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