Liberty Queens Med. v. Tri-State Consumer Ins

In Liberty Queens Med. v. Tri-State Consumer Ins. (188 Misc 2d 835 [Nassau Dist Ct 2001]) the court dealt directly with the apparent inconsistency between the Appellate Division precedent that the verification requirements must be strictly complied with and the regulatory language which provided for an extension of time in which a defendant insurer had to pay or deny a claim based upon outstanding verification pursuant to 11NYCRR 65.15 (d) (2) and (g) (1) (under the new regulations--11 NYCRR 65-3.6 [b] and 65-3.8 [j]). There, the defendant insurer made the additional verification request 11 days after receiving the claim and hence was one day late in making the request pursuant to 11 NYCRR 65.15 (d) (2). The plaintiff argued that because the request for additional verification was untimely, the defendant insurer waived its right to extend the 30-day period and therefore was required to make a determination on the claim within 30 days of the initial submission, citing Presbyterian Hosp. in City of N.Y. v. Aetna Cas. & Sur. Co. (233 AD2d 431 [1996]). The Liberty court first distinguished the matter before it from Presbyterian where the court was not required by the facts before it to focus on the "specific issue presented here," i.e., the tolling provision of section 65.15 (g) (10). (188 Misc 2d at 839.) Therefore, the "broad general language" utilized by the Presbyterian court should not be construed as determinative of how the court should rule upon a one-day delay in complying with the specific regulation before it. (Id.). Addressing the insured's "one-day deviation" from the requirement that it send its additional verification request within 10 days, the court found that the purpose of the No-Fault Law--"avoiding prejudice to insureds by providing for prompt payment or disclaimers of claims"--was sufficiently served by "truncating the presumptive 30-day period which the insurer itself would otherwise have to eventually review the proof submitted" as set forth in 11NYCRR 65.15 (g) (10). (Liberty at 840.) To impose the "draconian result" requested by plaintiff for a "one-day deviation" from the promulgated standards would deprive the insurer entirely of its right to obtain and review the needed proof and would "contravene rather than implement the statutory intent." (Id.)