Opinion
Index No. CV-733608-19
06-08-2021
BURKE 2 PHYSICAL THERAPY, P.C., A/A/O Sang, Sterneth, Plaintiff(s), v. STATE FARM MUTUAL AUTOMOBILE INS. CO. PIP/BI CLAIMS, Defendant(s).
Recitation, as required by CPLR § 2219(a), of the papers considered in the review of this motion and cross motion for summary judgment:
Papers/ Numbered
Notice of Motion and Affidavits/Affirmations Annexed 0O9NBM
Cross-Motion and Answering Affidavits E2E86J
Opposition/Reply Affidavits/Affirmations Q486UA
Memoranda of Law______
Other______
Defendant State Farm Mutual Automobile Ins. Co. PIP/BI Claims (hereinafter "State Farm") moves for an order, pursuant to CPLR § 3212 granting summary judgment and dismissing the complaint. Plaintiff Burke 2 Physical Therapy, P.C. (hereinafter "Burke"), A/A/O Sterneth Sang (hereinafter "Sang"), cross-moves for an order: pursuant to CPLR § 3211(c) and CPLR § 3212(a) granting summary judgment; denying defendant's motion; pursuant to CPLR § 3212(g) limiting the issues of fact for trial by finding that the prescribed statutory billing forms were mailed to and received by the insurance carrier and that payment of no-fault benefits is overdue; and pursuant to CPLR § 3211(b) to dismiss defendant's affirmative defenses.
Plaintiff commenced the instant action by filing the summons and complaint on July 2, 2019. Issue was joined on July 31, 2019. Sang allegedly sustained injuries in a motor vehicle accident on September 13, 2018 and defendant was the responsible no-fault insurance carrier. The accident was reported to defendant and a claim number was issued. Sang sought treatment with Burke on October 3, 2018 and assigned his claims to Burke on October 30, 2018. On September 14, 2018, prior to submission of the claim, an examination under oath (hereinafter "EUO") of Burke's owner, John Nasrinpay (hereinafter "Nasrinpay"), was held by defendant regarding claims unrelated to Sang. Nasrinpay's EUO pre-dated receipt of the bills in dispute in the instant matter. Nevertheless, defendant issued numerous verification requests in this action precipitated by Nasrinpay's EUO.
At issue in the instant matter are bills for dates of service from October 3, 2018, October 5, 2018, October 30, 2018, October 31, 2018, December 4, 2018, and December 11, 2018. State Farm acknowledged receipt of these claims. State Farm, by letters dated, December 3, 2018, December 17, 2018, January 23, 2019, and January 29, 2019, issued verification requests of the claims seeking production of numerous documents, including tax returns, bank records, and documents related to defendant's various operating locations. State Farm sent follow-up requests for verification on January 9, 2019, January 23, 2019, February 26, 2019, and March 6, 2019. Plaintiff's counsel alleges that Burke "replied to every verification request in a timely manner." Those letters of response to the verification requests and any proof that they were mailed were not attached to the instant motion. State Farm issued denial of claim forms (NF-10s) on April 8, 2019, April 23, 2019, and June 4, 2019.
State Farm contends that it timely requested verifications of the bills at issue in the instant matter, thus tolling their time to pay pursuant to 11 NYCRR § 65-3.5. Moreover, it alleges it properly denied plaintiff's claims for failure to provide the requested verification within 120 days. Defendant argues that the licensing of a medical provider is a condition precedent to the payment of no-fault benefits, therefore, such verification is relevant to the proof of the claim. Defendant contends that although it "need not demonstrate the ‘good cause’ of its verification requests," its basis for the requests is substantiated by the affidavit of State Farm's investigator, Lisa Stockburger. Defendant maintains its verification requests were proper and its denials timely.
In opposition, plaintiff argues that Nasrinpay's affidavit establishes that plaintiff responded to defendant's verification requests. Plaintiff alleges that the verification request were "impermissible and improper" as they were discovery requests that do not verify the claim but were "made merely to harass and burden the plaintiff." In support of its motion and in further opposition to defendant's motion, plaintiff annexes "Objections to Defendant's Verification Requests," undated but served on December 23, 2020, wherein plaintiff's counsel objected to defendant's verification and follow-up verification letters during the course of the instant litigation.
An insurer must pay or deny a claim in whole or in part within 30 calendar days after receipt of proof of claim. See 11 NYCRR § 65-3.8(c) ; Insurance Law § 5106(a). Proof of claim includes "verification of all of the relevant information requested pursuant to section 65-3.5 of this Subpart." 11 NYCRR § 65-3.8(a) ; see New York Univ. Hosp. Tisch Inst. v Govt. Employees Ins. Co. , 117 AD3d 1012, 1013 (2d Dept 2014). An insurer can extend or toll its time to pay or deny a claim by forwarding verification forms within 15 business days of receipt of the claim. See 11 NYCRR § 65-3.5(b) ; Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. , 120 AD3d 561, 563 (2d Dept 2014) ; Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. , 106 AD3d 157, 163 (2d Dept 2013). If any of the requested verifications are not "supplied to the insurer 30 calendar days after the original request, the insurer shall, within 10 calendar days, follow up with the party from whom the verification was requested" 11 NYCRR § 65-3.6(b) ; see Westchester Med. Ctr. v Allstate Ins. Co. , 112 AD3d 916, 917 (2d Dept 2013).
Although verification of a claim is permitted pursuant to 11 NYCRR § 65-3.5(c), "the no-fault regulations do not specifically define or limit the information or documentation an insurer may request through verification." Victory Med. Diagnostics, P.C. v Nationwide Prop. and Cas. Ins. Co., 36 Misc 3d 568, 573 (NY Dist Ct 2012). Litigants sometimes refer to a response to a verification request as an "objection letter," but "[n]either the no-fault law nor the no-fault regulations establish a mechanism or procedure by which a claimant provider can contest or challenge a request for verification on the grounds it is improper, unduly burdensome, unfounded, unnecessary or harassing." Id. at 573 ; c f Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553, 555 (2d Dept 1999) (holding that "[a]ny confusion on the part of the plaintiff as to what was being sought [in the verification letters] should have been addressed by further communication, not inaction"); Healthy Way Acupuncture, P.C. v NY Cent. Mut. Fire Ins. Co. , 58 Misc 3d 137 (App Term 2017). However, a demand for verification of facts can only be made if "there are good reasons to do so." 11 NYCRR § 65-3.2(c). An insurer "is entitled to receive all items necessary to verify the claim directly from the parties from whom such verification was requested." 11 NYCRR § 65-3.5(c). The Superintendent's regulations provide for agency oversight of insurance carriers, and demand that carriers "delay the payment of claims to pursue investigations solely for ‘good cause’ " State Farm Mut. Auto. Ins. Co. v Robert Mallela, 4 NY3d 313, 322 (2005) ; see 11 NYCRR § 65-3.2 (c). In the licensing context, "carriers will be unable to show "good cause" unless they can demonstrate behavior tantamount to fraud." State Farm Mut. Auto. Ins. Co. v Robert Mallela, 4 NY3d at 322.
11 NYCRR § 65—3.5 (o) provides that a verification letter must be responded to by either submitting "all such verification under the applicant's control or possession or written proof providing reasonable justification for the failure to comply." If the claimant fails to respond to the verification letters, "an insurer may issue a denial if, more than 120 calendar days after the initial request for verification, the applicant has not submitted all such verification under the applicant's control or possession or written proof providing reasonable justification for the failure to comply, provided that the verification request so advised the applicant as required in section 65-3.5(o) of this Subpart." 11 NYCRR § 65-3.5 (b)(3).
In the instant matter, although the EUO of plaintiff occurred prior to receipt of the claim, the request for verification was sent after the claim was received. Therefore, the verification request tolled defendant's time to deny the claim. See Clear Water Psychological Services, P.C. v Hereford Ins. Co., 68 Misc 3d 127(A) (App Term 2020). The follow-up verifications letters were also timely. Defendant's verification letters, in compliance with 11 NYCRR § 65-3.5(o), notified plaintiff that it was required to provide all documents requested or provide written proof of a reasonable justification for its failure to comply.
Notably, plaintiff's statements fluctuate between arguing that they provided the documentation and that State Farm is not entitled to such documentation. While plaintiff attests that it timely responded to the verification requests, it fails to attach such letters in response to the instant motion. Moreover, the affidavit of Nasrinpay states that he "personally responded and mailed on 01/18/2019, 02/06/2019 and 03/26/19 the verification responses in issue in this case to the address designated by defendant on the verification requests, to the extent such response was proper and in my possession." Cross-Motion, p 160, ¶ 5. Nasrinpay fails to attach his responses to the verification letters to illustrate what was produced or to provide written proof of a reasonable justification for the failure to comply. Additionally, his affidavit fails to detail what was allegedly mailed to defendant. Defendant denies having received any such correspondence from plaintiff before issuing the NF-10 denials of its claims.
Furthermore, although 11 NYCRR § 65-3.5(o) provides for a response which allows for written proof of reasonable justification for the failure to comply with a verification request, no such response was submitted in support of this motion. Plaintiff's counsel submits an "objection" to the verification request, which is not a proper response to defendant's verification requests as it is not timely pursuant to 11 NYCRR § 65-3.5(o). Moreover, the "objection" appears to reference Mallela materials sought during litigation. The Court notes that the instant action was commenced on July 2, 2019 and plaintiff's "objection" was served over 18 months after commencement of the action and over 2 years after the initial verification request was made. Therefore, plaintiff failed to submit proof that it complied with § 11 NYCRR § 65-3.5(o). Finally, the Court finds the remainder of plaintiff's arguments to be pro forma, without merit, and specious.
Accordingly, defendant's motion pursuant to CPLR § 3212 for summary judgement dismissing the complaint is granted in its entirety and plaintiff's cross-motion is denied as moot.
The foregoing constitutes the decision and order of this Court.