AAO ANA LOPEZ v. Maya Assurance Co, Defendant(s) (2026)

Plaintiff Baldwin Medical Services, P.C. ("Baldwin"), as assignee of Ana Lopez, seeks reimbursement from defendant Maya Assurance Co. ("Maya") for medical services provided by it in accordance with New York State No-Fault Law. Maya now moves for summary judgment, arguing that Baldwin's failure to respond to additional verification requests warrants dismissal (CPLR 3212). Baldwin opposes the motion. Issue has been joined and the motion was timely brought after notice of trial was filed. For the reasons that follow, Maya's motion for summary judgment is denied.

Relevant facts

On 3/2/22, Ana Lopez was allegedly injured in an automobile accident. On 5/17/22, Baldwin allegedly provided medical services to Ms. Lopez and now seeks reimbursement for those services from Maya, Ms. Lopez's insurer. Specifically, Baldwin billed $408.16 for bilateral paravertebral facet joint injections to the cervical and thoracic spine with image guidance, and arthrocentesis to the left shoulder rendered on 5/17/22.

By letter dated 6/15/22, Sanders Grossman Aranova, PLLC ("SGA PLLC") advised Maya that the firm had been retained by Baldwin and submitted the subject claim for reimbursement. The 6/15/22 letter further provides that "[p]ursuant to New York State Insurance Law, all requests for additional verification, denials and explanations of benefits must be mailed both to the above-referenced provider and this office" (emphasis in original). The claim form submitted by SGA PLLC lacked Ms. Lopez's signature in the portions authorizing release of information, requesting payment of benefits, and assigning benefits to the provider. Instead, the form stated that her signature was 'on file.'

Maya claims that it then sent an additional verification request on 7/7/22 and a second additional verification request on 8/5/22 seeking an NF-3 completed and signed by the provider and a completed and signed Assignment of Benefits. Copies of verification requests addressed to Baldwin care of SGA PLLC at SGA PLLC's mailing address have been provided to the Court.

Meanwhile, while the additional verification was still pending, Baldwin commenced this action on 8/23/22. Baldwin alleges in its complaint that it did not receive requests for additional verification from defendant (see Summons and Complaint, ¶ 21 [NYSCEF Doc. No. 1]). Defendant does not argue in this motion that this action was prematurely commenced, although defendant has preserved this defense in its answer (fourth and seventh affirmative defenses).

On 1/25/23, Maya sent Baldwin an NF-10 Denial of Claim Form which denied payment for the subject claim on the grounds that Maya requested, but never received, additional information which it needed to verify Baldwin's claim or reasonable justification for the failure to comply with the verification request. The Explanation of Benefits attached to the Denial of Claim Form specifically states: "Our 1st verification letter was mailed out on 07/08/22 which 120 days have passed."

Parties' arguments

Defendant seeks summary judgment on the grounds that it properly denied plaintiff's bill based on plaintiff's failure to provide additional verification requested. Maya contends that after receiving the claim, it mailed the initial request for additional verification on 7/7/22 and a second additional verification request on 8/5/22, and that Baldwin did not respond to either. Maya further argues that because no verification or reasonable justification was provided within 120 days of the initial verification request, it properly issued an NF-10 denial on 1/25/23 pursuant to 11 NYCRR 65-3.5 (o).

Plaintiff does not dispute verifications were not answered. Rather, plaintiff argues in opposition that defendant failed to establish the verification requests were timely and properly mailed, or at least a triable issue of fact remains as to such. Plaintiff further argues that defendant failed to establish that it complied with applicable No-Fault regulations by mailing its verification requests to both plaintiff and plaintiff's attorney and that defendant has failed to demonstrate a "good reason" for delaying plaintiff's claim.

Discussion

On a motion for summary judgment, the proponent bears the initial burden of setting forth evidentiary facts to prove a prima facie case that would entitle it to judgment in its favor, without the need for a trial (CPLR 3212; Winegrad v New York Univ. Med. Ctr., 64 NY2d 851 [1985]; Zuckerman v City of New York, 49 NY2d 557, 562 [1980]). If the proponent fails to make out its prima facie case for summary judgment, however, then its motion must be denied, regardless of the sufficiency of the opposing papers (Alvarez v Prospect Hosp., 68 NY2d 320 [1986]; Ayotte v Gervasio, 81 NY2d 1062 [1993]).

Granting a motion for summary judgment is the functional equivalent of a trial, therefore it is a drastic remedy that should not be granted where there is any doubt as to the existence of a triable issue (Rotuba Extruders v Ceppos, 46 NY2d 223 [1978]). The court's function on these motions is limited to "issue finding," not "issue determination" (Sillman v Twentieth Century-Fox Film Corp., 3 NY2d 395 [1957]).

Pursuant to the No-Fault regulations, generally, an insurer must pay or deny a claim for medical services within 30 calendar days after proof of the claim is received (11 NYCRR 65-3.8 [a] [1]). However, an insurer may toll the 30-day period to pay or deny a claim by requesting additional verification to establish proof of the claim within 15 business days of receipt of the claim (11 NYCRR 65-3.5 [b]). If the insurer has not received the requested verification within 30 days of the initial request, then it "shall, within 10 calendar days, follow up with the party from whom the verification was requested, either by telephone call or by mail. At the same time the insurer shall inform the applicant and such person's attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested." (11 NYCRR 65-3.6 [b]).

An insurer shall not issue a denial of claim form prior to its receipt of verification of all relevant information requested by the insurer (11 NYCRR 65-3.8 [b] [3]; see Omega Diagnostic Imaging, P.C. v MVAIC, 32 Misc 3d 128(A) [App Term, 1st Dept 2011]). However, pursuant to 11 NYCRR 65-3.5(o), an insurer may deny the claim after 120 calendar days if the party from whom verification is requested does not provide all the requested verification under its control or possession, or written proof providing reasonable justification for its failure to comply.

The information sought in a verification request "must have some rational relationship to the specific claims" (see Medical Supply of NY Direct Servs. Corp. v State Farm Ins. Co., 88 Misc 3d 1252(A) [Civ Ct, Richmond County 2026]; Doshi Diagnostic Imaging Servs. v State Farm Ins. Co., 16 Misc 3d 42 [App Term, 9th & 10th Jud Dists 2007]). At the outset, the Court rejects Baldwin's argument that Maya lacked a good reason for seeking the requested information. An NF-3 signed by the provider and proof of assignment from Ms. Lopez are plainly rationally related to the claim and facially reasonable given the claim form submitted by SGA PLLC lacked the relevant information.

However, for an insurer to succeed on a motion for summary judgment based upon the failure to respond to verification requests, there must be evidence the requests were sent and that the party failed to provide the information and failed to provide any reasonable justification for noncompliance (Burke Physical Therapy P.C. v State Farm Mut. Auto. Ins. Co., 75 Misc 3d 143(A) [App Term, 2d Dept, 9th & 10th Jud Dists 2022]). Proof that a letter was properly mailed creates a rebuttable presumption that the letter was received by the addressee (Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]). One way such proof can be established is through proof of office practices and procedures that ensure items are properly addressed and mailed (New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2d Dept 2006]).

Defendant submitted the affidavit of Ryan Donnelly, a claims adjuster employed by Maya as proof of its mailing practices. Mr. Donnelly states that he has been employed by Maya since February 8, 2021, and that it is his duty to ensure compliance with the procedures described in his affidavit (see Affidavit of Ryan Donnelly, ¶ 16).

The Court finds that no presumption of mailing is created for the 7/7/22 verification request. Mr. Donnelly's affidavit does not describe the office's mailing practices and procedures applicable to the initial request. While Mr. Donnelly is the person who prepared both verification requests and his affidavit details Maya's office mailing practices and procedures for the second additional verification request dated 8/5/22 (see Affidavit of Ryan Donnelly, ¶ 10 [NYSCEF Doc. No. 10]), Mr. Donnelly does not state that the same procedures were followed with respect to mailing of the initial request, describe what standard mailing practices were in place on the relevant date nor does Mr. Donnelly state that Maya followed uniform mailing practices during the relevant period.

Regarding the initial request, Mr. Donnelly states only that he "placed the window envelope containing the duplicate verification request letter in the 'out' box for the support department to process," without detailing the steps taken by the support department to process the letter to ensure proper mailing and receipt (emphasis added). Moreover, the use of the word duplicate in relation to the first verification request is unexplained by Mr. Donnelly or defense counsel. Thus, Mr. Donnelly's affidavit is insufficient to establish the presumption of mailing with respect to defendant's initial verification request.

Further, even if Donnelly's affidavit were sufficient, the NF-10 states that the first verification request was sent on 7/8/22, not 7/7/22 as Maya contends. This inconsistency itself raises a triable issue of fact as to when the first verification request was mailed.

Therefore, the Court finds that Maya failed to meet its burden of establishing its prima facie defense that it timely and properly mailed its requests for additional verification, thereby tolling the 30-day period in which to pay or deny plaintiff's claim.

Baldwin's remaining arguments

Having determined that Maya has not proven its timely and proper mailing of the verification requests, the Court will address Baldwin's remaining argument that the additional verification was not properly sent to both Baldwin and its attorney. Plaintiff cites 11 NYCRR 65-3.6 (b), which requires the insurer to follow up with the party from whom the verification was requested, either by telephone call or by mail, and "[a]t the same time inform the 'applicant' and such person's attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested" (see e.g. Doshi Diagnostic Imaging Services v State Farm Ins. Co., 16 Misc 3d 42 [App Term, 2d Dept, 9th and 10th Jud. Dists. 2007]). As the Court explained in Doshi, "[w]here verification is sought from a party other than the applicant, the applicant is entitled to be timely informed of the nature of the verification sought and from whom it is requested when, after an initial verification request remains unsatisfied, a follow-up request is necessary."

Plaintiff's counsel misconstrues 11 NYCRR 65-3.6 (b), which does not stand for the proposition that Maya's verification requests were not properly sent because they were not separately sent to both Baldwin and SGA PLLC. This No-Fault regulation only requires notice to the applicant (the party seeking payment on a claim) and its attorney where the verification request is sent to a third party, not where the verification request is sent to the applicant itself (GNK Medical Supply, Inc. v Tri-State Consumer Ins. Co., 37 Misc 3d 138(A) [App Term, 1st Dept 2012]). Here, the verification request was directed to Baldwin, through its attorney, who had filed the claim. Nor does section 65-3.6 (b) require Maya to send two separate verification requests to both Baldwin and its attorney when Baldwin's claim was filed by its attorney who clearly stated in the 6/15/22 letter that it was retained by Baldwin in connection with the underlying claim. This Court is unaware of any other court that has reached such a holding, and such a requirement would be manifestly unfair where it is not only undisputed that Baldwin did not respond to Maya's verification requests, but Baldwin does not claim any prejudice resulting from Maya sending its verification requests to Baldwin's attorney.

Baldwin's attorney clearly put Maya on notice that it was the agent for Baldwin with respect to the claim submitted and thus "sending the verification request to the attorneys was the same as sending the request to the principal," regardless of whatever directions Baldwin's attorney puts in their pro forma letters (Lenox Hill Radiology v Global Liberty Ins. Co. of NY, 20 Misc 3d 434 [Civ Ct, NY County 2008] quoting Bauer v CS-Graces, LLC, 48 AD3d 922 [3d Dept 2008] ["The law is well settled that, unless obtained confidentially, 'knowledge acquired by an agent acting within the scope of [their] agency is imputed to [their] principal and the latter is bound by such knowledge' "]).

Moreover, "[a]ny confusion on the part of the plaintiff as to what was being sought should have been addressed by further communication, not inaction" (Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553 [2d Dept 1999]; see also Advantage Radiology, P.C. v Nationwide Mut. Ins. Co., 55 Misc 3d 91 [App Term, 2d Dept, 9th & 10th Jud Dists 2017]). Therefore, plaintiff's argument that Maya's denial was improper because copies of Maya's verification requests were not sent to both Baldwin and Baldwin's attorney is rejected. Thus, it remains for trial to determine whether Maya timely and properly mailed its verification requests. If that defense is proven, then this action was prematurely commenced since Maya's verification requests were still outstanding at the time Baldwin filed its summons and complaint.

Conclusion

In accordance herewith, it is hereby

ORDERED that defendant's motion for summary judgment is denied.

This action is ready for trial and remains on the Court's calendar for a virtual appearance on September 9, 2026 at 11:00AM.

Any requested relief not expressly addressed herein has nonetheless been considered and is hereby denied.

This constitutes the decision and order of the Court.

Date: 08/19/2026

Hon. Eric J. Wursthorn

Civil Court Judge (NYC)

Eric J. Wursthorn, J.