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Denial of “Defective” No-Fault Claim (on Form UB-40) Was of No Effect—Failure to Respond Within 30 Days to a Subsequent “Correct” Claim (on Form NF-5) Precluded Insurer from Raising Defenses to the Claim

The Second Department determined the insurer’s denial of a defective claim was of no effect and the insurer’s failure to respond to the valid claim within 30 days precluded raising defenses to the claim:

[The insurer] contends that the 30-day period commenced when it received the Form UB-04 in December 2011, that it timely requested verification of the claim, and that, after it received the medical records, it timely denied the claim in January 2012. [the hospital] could not commence the 30-day clock anew by submitting the same claim several months later … .

We conclude that the Supreme Court erred in denying [the hospital’s] motion for summary judgment on the complaint and in granting [the insurer’s] cross motion for summary judgment dismissing the complaint. Under our decision in Sound Shore [106 AD3d 157], the 30-day period for [the insurer] to pay or deny the claim did not begin to run until March 26, 2012, when [the hospital] submitted the Form NF-5, which contained the information needed. Because [the insurer] did not pay or deny the claim within 30 days thereafter, it was precluded from raising defenses. In other words, the defective “claim” submitted in December 2011 did not start the 30-day clock, so [the insurer’s] denial in January 2012 was of no effect … . Mount Sinai Hosp v New York Cent Mut Fire Ins Co, 2014 NY Slip Op 05779, 2nd Dept 8-13-14

 

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