13.3 A&H Claims Handling: Notice, Claim Forms, Proof of Loss, Physical Examination & New York Prompt Pay
Key Takeaways
- New York individual accident and health policies must contain standard provisions under Insurance Law § 3216(d) that may be made more favourable to the insured but never less favourable.
- Notice of claim is due within 20 days or as soon thereafter as reasonably possible; the insurer must furnish claim forms within 15 days of that notice.
- Proof of loss is due within 90 days, extendable where it was not reasonably possible and, absent legal incapacity, no later than one year after the deadline.
- No suit may be brought before 60 days after proof of loss is furnished, and none after three years from the date proof was required.
- Insurance Law § 3224-a requires payment of undisputed health claims within 30 days if filed electronically or 45 days otherwise, with 12% per annum interest (or the corporate tax rate, if greater) on violations.
A&H Claims Handling: Notice, Claim Forms, Proof of Loss, Physical Examination & New York Prompt Pay
Exam Focus: The accident and health claim clock is built from the standard provisions in New York Insurance Law § 3216(d) and layered with the Prompt Pay Law, § 3224-a. Memorise the sequence — 20 days' notice, 15 days to furnish forms, 90 days for proof of loss, 60 days before suit and three years after — and the 30/45-day prompt-pay deadlines with 12% interest.
The Standard Provisions Framework
New York individual accident and health policies must contain a set of required standard provisions (Insurance Law § 3216(d)(1)) and may contain certain optional provisions. The required provisions are drafted to protect the insured, so a policy may make them more favourable to the insured but never less.
Step 1 — Notice of Claim: 20 Days
Written notice of claim must be given to the insurer within 20 days after the occurrence or commencement of any loss covered by the policy, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the insured or beneficiary to the insurer, or to any authorised agent, with information sufficient to identify the insured, is deemed notice to the insurer.
Reasonableness escape hatch. The phrase “or as soon thereafter as is reasonably possible” is the reason late-notice denials on A&H claims rarely survive. A claimant in a coma for six weeks has not forfeited the claim.
Step 2 — Claim Forms: 15 Days
On receipt of notice, the insurer must furnish the claimant with the forms it customarily requires for filing proofs of loss within 15 days. If the insurer fails to do so, the claimant is deemed to have complied with the proof-of-loss requirement by submitting written proof of the occurrence, character and extent of the loss within the proof-of-loss time limit. The burden of producing the form sits on the carrier, not the claimant.
Step 3 — Proof of Loss: 90 Days
Written proof of loss must be furnished within 90 days after the termination of the period for which the insurer is liable (for a periodic disability benefit) or within 90 days after the date of the loss (for any other loss). Failure to furnish proof within that time does not invalidate or reduce the claim if it was not reasonably possible to do so, provided proof is furnished as soon as reasonably possible and, except in the absence of legal capacity, no later than one year after the deadline.
Step 4 — Time of Payment of Claims
Benefits payable other than periodic indemnity are paid immediately on receipt of due written proof. Periodic disability indemnity is paid at the intervals stated in the policy, at least monthly, with any unpaid balance paid immediately on receipt of proof at the end of liability.
Step 5 — Physical Examination and Autopsy
The insurer has the right, at its own expense, to examine the person of the insured as often as reasonably required while a claim is pending, and to make an autopsy in case of death where it is not forbidden by law. This is the A&H analogue of the property examination under oath — an investigative right that must be exercised reasonably and at the carrier's cost.
Step 6 — Legal Actions
No action at law or in equity may be brought to recover on the policy prior to the expiration of 60 days after written proof of loss has been furnished, and no action may be brought after three years from the time written proof of loss is required to be furnished. The 60-day floor gives the carrier a window to adjust; the three-year ceiling is the contractual limitation period.
| Standard provision | Deadline | Who bears it |
|---|---|---|
| Notice of claim | 20 days (or as soon as reasonably possible) | Claimant |
| Furnish claim forms | 15 days from notice | Insurer |
| Proof of loss | 90 days (extendable to 1 year if not reasonably possible) | Claimant |
| Payment of non-periodic claims | Immediately on receipt of due proof | Insurer |
| Minimum wait before suit | 60 days after proof of loss | Claimant |
| Contractual limitation on suit | 3 years from when proof was due | Claimant |
New York's Prompt Pay Law (Insurance Law § 3224-a)
Layered on top of the standard provisions is New York's Prompt Pay Law, which governs the timing of payments to policyholders, covered persons and health care providers.
- Undisputed claims: must be paid within 30 days of receipt if the claim was transmitted electronically, and within 45 days if submitted by any other means.
- Disputed claims: where the obligation to pay is not reasonably clear because of a good-faith dispute over eligibility, another carrier's liability, the amount, the benefits covered, or how services were accessed, the insurer must pay any undisputed portion and, within 30 days of receipt, notify the policyholder or provider in writing of the reason it is not liable, or request the specific additional information it needs.
- Fraud exception: the deadlines do not apply where there is a reasonable basis, supported by specific information available for review by the Superintendent, that the claim or bill was submitted fraudulently.
- Interest penalty: a violation obligates the insurer to pay the claim plus interest at 12% per annum, or the corporate tax rate set by the Department of Taxation and Finance, whichever is greater, computed from the date payment was due.
- Provider submission window: health care claims must generally be submitted by the provider within 120 days after the date of service to be valid and enforceable.
Contrast with No-Fault. Article 51 no-fault health service bills run on their own 30-day clock under Insurance Law § 5106 with 2% per month interest — not on § 3224-a. An adjuster holding the 17-72 no-fault and workers' compensation health services line must keep the two regimes separate.
Utilization Review and External Appeal
A denial resting on medical necessity or on an experimental/investigational determination is a utilization review denial, not a simple coverage denial, and New York routes it through Insurance Law Articles 49:
- Internal appeal to the insurer, with a determination on a standard appeal due within 30 days of receipt of the necessary information.
- External appeal to an independent external appeal agent certified by the Department of Financial Services. The agent's determination is binding on the insurer.
Documenting which track a denial belongs on is part of a defensible claim file; mislabelling a utilization review denial as an administrative denial is itself a compliance exposure.
Practical Claim Sequence
A Syracuse insured is hospitalised on March 3 after a fall.
- By March 23 (20 days) the insured gives notice of claim to the carrier.
- By April 7 (15 days from notice) the carrier must furnish proof-of-loss forms. If it does not, the insured satisfies the requirement with any written statement of the occurrence, character and extent of the loss.
- By June 1 (90 days from the loss) the insured furnishes written proof of loss.
- The hospital submits its bill electronically; the carrier must pay the undisputed amount within 30 days or, within 30 days, explain in writing why it is not liable or request specific additional information.
- The insured cannot sue before August 1 (60 days after proof) and must sue by roughly June 2029 (three years from when proof was due).
A New York individual accident and health insurer receives notice of claim but never sends the claimant its customary proof-of-loss forms. What is the consequence under the standard provisions of Insurance Law § 3216(d)?
Under New York Insurance Law § 3224-a, within what period must an insurer pay an undisputed health care claim that was transmitted electronically, and what interest rate attaches to a violation?