Doshi Diagnostic Imaging Services v. State Farm Insurance Co.

• Decision Date: 16 March 2007
• Docket Number: No. 2006-169 N C,2006-169 N C
• Citation: 2007 NY Slip Op 27193,842 N.Y.S.2d 153,16 Misc.3d 42
• Parties: DOSHI DIAGNOSTIC IMAGING SERVICES, as Assignee of LATICIA VAZQUEZ, Appellant, v. STATE FARM INSURANCE CO., Respondent.
• Court: New York Supreme Court — Appellate Term

16 Misc.3d 42

842 N.Y.S.2d 153

2007 NY Slip Op 27193

DOSHI DIAGNOSTIC IMAGING SERVICES, as Assignee of LATICIA VAZQUEZ, Appellant, v. STATE FARM INSURANCE CO., Respondent.

No. 2006-169 N C

Supreme Court, Appellate Term, Second Department.

March 16, 2007.

Friedman, Harfenist, Langer & Kraut, Lake Success (Neil Torczyner of counsel), for appellant.

OPINION OF THE COURT MEMORANDUM.

Order affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the action as premature due to outstanding requests for verification. The court granted defendant's cross motion and this appeal by plaintiff ensued.

After receiving the claim, defendant issued a letter to the prescribing physician requesting verification of the medical necessity of the MRI performed at plaintiff's facility and detailing the information sought. On the same day, defendant advised plaintiff by letter that the claim's determination would be delayed pending receipt of medical necessity verification from the prescribing physician. The initial verification request remained unsatisfied after 30 days, whereupon defendant followed up its request to the prescribing physician and sent plaintiff a copy of the request and a second letter, nearly identical to the first, to the effect that a decision on the claim was being delayed pending medical necessity verification. Plaintiff objects only to defendant's failure to seek the verification directly from plaintiff as, plaintiff insists, the regulations require. Contrary to plaintiff's contention, the record establishes that the letters sent by defendant sufficed to toll the statutory claim determination period (Insurance Law § 5106 [a]; 11 NYCRR 65-3.2 [c]; 65-3.5 [a], [c]; 65-3.6 [b]).

The insurance regulations require that there be "good reasons" to demand verification (11 NYCRR 65-3.2 [c]), that the demand be directed "as expeditiously as possible" (id.) to the "parties required to complete them" (11 NYCRR 65-3.5 [a]), and that the insurer is entitled to receive the verification "directly from the parties from whom such verification was requested" (11 NYCRR 65-3.5 [c]). We do not construe the reference to "parties" to be limited to an applicant for no-fault benefits. By its terms, 11 NYCRR 65-3.6 (b) requires the insurer to inform the "applicant" of the nature of previously requested and unproduced verification, the identity of "the party from whom it was requested," and that the request is renewed. The provisions clearly contemplate that an applicant may not be the only appropriate "party" from whom, for example, medical necessity verification may most readily be obtained (e.g. a medical equipment...