Index No. CV-734838-24/R1. Civil Court of the City of New York, Richmond County. Decided March 26, 2025.
ROBERT J. HELBOCK, J.
The decision on Defendant’s Motion for Summary Judgment is as follows:
Plaintiff, FIRST STOP P.T., P.C. (hereafter “Plaintiff” or “First Stop”), as assignee of Sandy Molina (hereafter “Assignor”), commenced this action against the defendant, GEICO INSURANCE COMPANY (hereinafter, “Defendant”), to recover assigned first-party No-Fault insurance benefits for medical treatment provided to the Assignor pursuant to an automobile insurance policy issued by the Defendant.
Currently before the Court is Defendant’s motion seeking (i) an order pursuant to CPLR §3212 to grant summary judgment to the Defendant on the grounds that Plaintiff failed to provide GEICO with response to written demands for verification requested pursuant to the N.Y.S. Insurance Department regulation. (11 N.Y.C.R.R. §65-3.5).
Factual Background
The Court finds the following facts relevant to the decision in this matter.
The Defendant received a bill on May 23, 2023 for treatment rendered by the Plaintiff to the Assignor on April 14, 2023 in the amount of $614.00. On June 6, 2023 the Defendant requested the Plaintiff to appear for an “examination under oath (hereafter referred to as “EUO”) to take place on July 18, 2023, which was eventually rescheduled to August 29, 2023.
In the same letter making the EUO request dated June 6, 2023, the Defendant asked the Plaintiff to produce the following documents no later than seven days prior to the EUO:
- “Sign in sheets, treatment notes, evaluation and reevaluation reports, and referrals from other healthcare providers to the extent not already provided;
- Documents evidencing ownership of First Stop at the time of treatment for which you seek payment, by one or more licensed professionals, including but not limited to a copy of the certificate of incorporation, receipts for filing, stock certificates and the stock ledger for the professional corporation;
- A list of the individuals who provide healthcare services on behalf of First Stop, licensing documentation for those individuals, and documents identifying the relationship between each individual and First Stop (i.e. W2s, 1099s, and/or K-1s);
- Documents relating to the income and expenses of First Stop, including but not limited to payroll tax returns, corporate tax returns, financial statements, general ledgers, and bank statements for the past 12 months; and
- Documents, contracts and agreements (including proofs of payments thereunder) relating to the relationship between First Stop and any entity or individual that (i) leases space and/or equipment to or First Stop or (ii) provides management, marketing, consulting, administrative, mailing, billing or collection services to First Stop.”
Both sides agree that the Plaintiff appeared for the EUO on August 29, 2024. Then on September 1, 2023 the Defendant’s attorney sent a follow-up letter to the Plaintiff demanding additional documentation, including leases, employee lists, licensing records, billing agreements, referral forms, employment documentation, and marketing materials.
The Defendant issued additional follow-up letters dated September 18, 2023 and October 24, 2023 requesting the same information.
The Plaintiff responded by a letter dated December 28, 2023, raising objections and providing partial documentation, including leases, payroll records, licensing certificates, and checks. Some requests were objected to as overbroad or irrelevant, and certain documents were not provided.
By NF-10 denial dated January 25, 2024, the Defendant denied payment on the ground that Plaintiff failed to comply with verification requests within 120 days.
The Plaintiff commenced this action on June 20, 2024.
Discussion
The claim procedures for No-Fault benefits are governed by 11 NYCRR §65-3 et seq. Section 65-3.5 requires:
- Initial verification requests within 10 business days
- Subsequent verification requests within 15 business days
- Follow-up requests if no response within 30 days
The Court notes that while follow-up requests are permitted, additional or “new” verification requests made beyond the regulatory timeframe are not valid to toll the denial period.
The Defendant’s June 6, 2023 letter constituted the valid subsequent verification request. The September 1, 2023 letter partly reiterated prior requests but also introduced new requests beyond the 15-day limit, rendering those new requests a nullity.
However, Plaintiff remained obligated to respond to the outstanding items from the June 6, 2023 request.
The Plaintiff’s December 28, 2023 response provided partial documentation. Whether this response satisfied the verification requirements is a material issue of fact.
Decision
The Court finds that a triable issue of fact exists as to whether Plaintiff’s December 28, 2023 response satisfied the June 6, 2023 verification request.
Accordingly, Defendant’s motion for summary judgment is DENIED, and the matter is referred to trial on the issue of compliance with verification requests.
This is the decision and order of the Court.