Comments for Arbiters of NY No-Fault

Comment on No AOB = Denial by Bethany Mazur

Bethany Mazur — Thu, 06 May 2010 12:48:48 +0000

Again, you note the court refers to the “hospital’s standing.” I cannot agree with you that this decision should apply to each and every provider an EIP treats with… it would be entirely too easy for fraudulent providers to submit claims for treatment that was never even rendered. I think the Court of Appeals consistently referred to the plaintiff in this case as “hospital” and not “provider” for that exact reason. So I can agree with you that yes, the Court of Appeals has decided that an insurer cannot challenge a hospital’s standing if the insurer does not seek timely verification. As for other providers, where the EIP likely does not stay in their care for an extended amount of time or have his signature on file – I do not believe this decision is that broad.

We also do not know if the insurer did in fact request verification of the AOB here…

As for the other “serious challenges” referred to by the arbitrator, the way I read the decision is simply that he chose to deny without prejudice so the parties could ‘get their ducks in a row,’ so to speak. In speaking with Applicant’s attorney, “serious challenges” seemed to be an understatement. I’m sure Applicant will be back with a valid AOB and solutions for whatever other issues wee presented. I’ll keep my eye out for a re-filing.

Comment on No AOB = Denial by David M. Gottlieb

David M. Gottlieb — Thu, 29 Apr 2010 02:14:22 +0000

You left out the first part of the quote, “Finally, Travelers contends that an assignment of benefits is a necessary component of the hospital’s prima facie case for recovery of no-fault benefits. Even assuming that this is true, we conclude that an assignment form stating that the patient’s signature is…”

Right before that the Court tells us, “Here, there is no dispute that the hospital rendered medical services to Browne in the amount of $24,344.96 for injuries arising out of a motor vehicle accident, that Browne’s policy with Travelers was in effect at the time of the accident and that the policy covered the accident. In our view, any defect or deficiency in the assignment between Browne and the hospital simply does not implicate a lack of coverage warranting exemption from the preclusion rule. We therefore determine that the failure by Travelers to seek verification of the assignment in a timely manner prevents the carrier from litigating the issue now.”

And who could forget that “[t]o allow an insurance company to later challenge a hospital’s standing as an assignee merely encourages the carrier to ignore the prescribed statutory scheme.”

Whatever other issues may have existed are irrelevant. Claims can’t be denied because of “serious challenges.” The arbitrator should have accounted for Joint Diseases in the decision. The Court of Appeals shouldn’t be brushed aside so easily.

Comment on No AOB = Denial by Bethany Mazur

Bethany Mazur — Fri, 23 Apr 2010 18:46:05 +0000

David – Hospital for Joint Diseases states that “an assignment form stating that the patient’s signature is ‘on file’ satisfies that burden where the carrier does not timely take action to verify the existence of a valid assignment.” We don’t know if there is a signature on file here, but I think we can assume there was not – it was Auto Rx, not a hospital where the assignor would have signed other forms. If you’ll note, even footnote “5″ in the Joint Diseases decision is a string cite consisting almost entirely of hospital plaintiffs.

Due to the short length of this arb decision we also don’t know what other issues may have existed. McCorry denied the claim without prejudice “in the absence of an appropriate assignment and in light of the other serious challenges asserted by the Respondent,” which we can’t determine from the decision. Chances are the AOB was an issue not for the purpose of lack of coverage, but instead for recovery and standing purposes.

Comment on No AOB = Denial by David M. Gottlieb

David M. Gottlieb — Fri, 23 Apr 2010 18:00:43 +0000

Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. 9 NY3d 312 (2007)?

Comment on No Need to Submit Bills After Pre-Authorization Claim Denied by Continuing Obligation to Submit? No Clear Consensus. « Arbiters of NY No-Fault

Wed, 17 Mar 2010 20:39:50 +0000

[...] month however, we had posted a February 17, 2010 decision by Arbitrator McCorry, in which he allowed a dental provider to recover benefits where it never [...]

Comment on Claimant Must Continue to Submit NF-7s for Lost Wages Even After Denial by Continuing Obligation to Submit? No Clear Consensus. « Arbiters of NY No-Fault

Wed, 17 Mar 2010 20:39:45 +0000

[...] recently posted a March 1, 2010 decision by Arbitrator O’Connor, in which she stated that a claimant must continue to submit claims [...]

Comment on Medical Literature Cited in Peer Review Subject to Review by Arbitrator by David M. Gottlieb

David M. Gottlieb — Mon, 01 Mar 2010 02:52:04 +0000

Part of the problem in finding them is the sloppy citation in peer reviews. Good catch on the article.

Comment on “Pilates” Provider Not Eligible for Reimbursement Under No Fault by David M. Gottlieb

David M. Gottlieb — Fri, 26 Feb 2010 17:43:29 +0000

The arbitrator found that it was inappropriate for the provider to bill under a physical therapy code when it was not a licensed physical therapist.

How does the arbitrator feel about acupuncturists?

Comment on Not Surprisingly, $80 Attorney’s Fee is Still the Maximum by Greg Vinal

Greg Vinal — Thu, 25 Feb 2010 15:25:26 +0000

The real question is what facts changed from the time of the original denial, or in other words what “good faith” basis was there for the original denial, that they are now conceding.

Comment on No Need to Submit Bills After Pre-Authorization Claim Denied by Larry Rogak

Larry Rogak — Wed, 24 Feb 2010 22:49:04 +0000

There’s that Domotor decision again. I will not rest until either it is held to be “no longer followed,” superceded by regulation, or the judges and arbitrators are all convinced that because every bill in no-fault is a separate “claim” (per LMK v. State Farm), blanket denials do not relieve claimants from the obligation to submit all future bills.