The Office of General Counsel issued the following opinion on June 30, 2003, representing the position of the New York State Insurance Department.
Re: Insurance Law Reg. 68 (11 NYCRR 65) Notice of Claim for No-Fault Health Services
Questions Presented:
1. How is the 45 day time period for filing of a claim for health service expenses specified in Insurance Regulation No. 68 measured?
2. Does Regulation No. 68 specify the form of "proof of mailing" that must be presented to verify timely claim filing by a health services provider?
Conclusions:
1. The claim for health service expenses must be mailed by the health care provider within 45 days after the date the services are rendered.
2. Regulation No. 68 does not require that the health care provider mail the no-fault claim to the insurer by any specified method, nor does it create a minimum or required standard as to what constitutes sufficient proof of mailing.
Facts:
There are no particular facts specified. The Department was advised that in certain instances insurers have insisted that claims be verified by production of certified mail return receipts.
Analysis:
Department of Insurance Regulation 68 (11 NYCRR § 65), which implements New York's No-Fault law, was first promulgated in 1974. The regulation has been amended on several occasions, including certain amendments that took effect on April 5, 2002. Insurers were required after April 5, 2002, to issue new prescribed endorsements with new and renewal policies containing the new requirements, including the following condition regarding claims for medical services:
Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the case of a claim for health service expenses, the eligible injured person or that persons assignee or representative shall submit written proof of claim to the Company, including full particulars of the nature and extent of the injuries and treatment received and contemplated, as soon as reasonably practicable but, in no event later than 45 days after the date services are rendered.
11 NYCRR § 65-1.1(d)(2002).
The "Consumers Frequently Asked Questions" regarding "About the New Automobile No-Fault Regulation 68" on the Insurance Department's website at http://www.ins.state.ny.us explains how the time frame for mailing of claims is to be applied. The relevant question and answer read as follows:
Do the new time period requirements run from the date that notice or submission of claims are made to the insurer or from the date that notice or submission of claims are received by the insurer?
Ans: The new time requirements apply as of the date that notice or submission of claims are made to the insurer. For example, if the accident occurs on January 1, notice of the claim must be mailed or submitted to the insurer no later than January 31 to comply with the notice requirement, which begins the day after the date of the accident.
With respect to the 45 day period for mailing of a written proof of claim for health service expenses, if the services were provided on January 1, the written proof of claim must be mailed to the insurer no later than February 15 to comply with the requirement. The 45 day period begins the day after the services are rendered.
The second question concerned whether the regulation requires any specific method for mailing of the notice to the insurer. No such requirement is contained in the regulation. Speaking to the specific situation noted in the inquiry, there is no underlying basis for an insurer to require that such notice be sent by certified mail with return receipt requested, although that would be one available method whereby the health service provider could chose to submit the notice of claim to the insurer. Whether or not a provider has provided sufficient proof of mailing in a particular instance is a question of fact, ultimately subject to determination by arbitration or by a court of competent jurisdiction.
For further information you may contact Associate Attorney Sam Wachtel at the New York City Office.