45-Day Rule for NY No-Fault Bills: What Carriers Must Prove to Deny a Late Submission

Key Takeaways

• Under 11 NYCRR 65-1.1, New York no-fault medical bills must generally be submitted within 45 days of the date services are rendered.
• A carrier moving for summary judgment on a 45-day defense must prove when the bill arrived — and in the First Department, that requires an affidavit describing the insurer’s practices for retrieving, opening, and indexing its mail.
• In SMB Med. P.C. v Chubb, the adjuster’s bare statement of a receipt date was not enough, and the carrier’s motion failed.
• The departments are split: Second Department case law has been more forgiving of conclusory receipt affidavits than the First.

Understanding the 45-Day Rule in No-Fault Insurance Claims

New York’s no-fault insurance system operates under strict timing requirements, with healthcare providers typically required to submit bills within 45 days of treatment. However, insurance companies cannot simply claim a bill was submitted late without proper documentation. A recent Appellate Term decision highlights the evidentiary standards required when insurers attempt to deny claims based on alleged late submissions.

The case demonstrates an important jurisdictional split between New York’s appellate departments regarding what constitutes sufficient proof of untimely billing submissions. While some courts have been more lenient with insurance company affidavits, this ruling establishes a higher bar for proving timing violations. The verification and claim-submission framework is complex — see the legal encyclopedia for a complete breakdown.

The Decision

Jason Tenenbaum’s Analysis:

SMB Med. P.C. v Chubb Indem. Ins. Co., 2015 NY Slip Op 50719(U)(App. Term 1st Dept. 2015)

“Defendant failed to establish its entitlement to summary judgment dismissing the complaint based upon plaintiff’s alleged untimely submission of the claims beyond the applicable 45-day time limit (see 11 NYCRR 65-1.1). The affidavit of defendant’s claims adjuster failed to describe defendant’s “regular practices and procedures in retrieving, opening, and indexing its mail and in maintaining its files on existing claims”

The First Department (unlike Second Department precedent) requires some type of discussion in the affidavit to allow the affiant to reach the conclusion that the billing was untimely submitted. Just saying the billing was received on some day is insufficient.

The Regulatory Framework: Where the 45 Days Comes From

The 45-day rule lives in the mandatory personal injury protection endorsement, 11 NYCRR 65-1.1. The endorsement requires that written proof of claim for health service expenses be submitted to the carrier no later than 45 days after the date services are rendered. The clock runs per date of service, which is why a single course of treatment can produce some timely bills and some untimely ones.

Two features of the regulation soften what would otherwise be a brutal deadline. First, the regulation contemplates that a late submission may be excused where the applicant provides a reasonable justification for the delay, and a denial premised on the 45-day rule must advise the applicant of the opportunity to supply that justification. Second — and this is where SMB Med. comes in — the 45-day defense is an affirmative defense the carrier must prove. The bill’s mailing date is usually undisputed; the fight is over when the carrier actually received it, and that receipt date is a fact within the carrier’s exclusive knowledge.

Proof of Receipt: Why Mailroom Affidavits Decide These Motions

How does a litigant prove the date a piece of mail arrived? The same way carriers prove their denials were mailed — through evidence of a standard office practice and procedure. New York courts accept proof of mailing (and by extension, proof of receipt and date-stamping) from an affiant who either has personal knowledge or who describes the office’s regular practices for handling the mail in question. The logic of cases addressing proof of mailing applies with equal force in reverse.

That is the gap that sank the carrier in SMB Med. The adjuster swore to a receipt date but never explained how the carrier retrieves, opens, indexes, and date-stamps incoming mail, or how its claim files are maintained. Without that foundation, the receipt date is a naked conclusion, and a naked conclusion does not carry a summary judgment burden. The First Department’s Appellate Term demands the foundation; Second Department precedent has historically tolerated thinner affidavits — a departmental split that makes venue worth checking before either side moves.

Why This Matters for Providers and Carriers

For medical providers, the decision is a shield. A 45-day denial supported only by an adjuster’s say-so about a receipt date is vulnerable, and opposition papers should attack the absence of any described mailroom procedure. This protects providers from unfounded late notice claims and ensures proper due process in timing disputes.

For carriers, the decision is a checklist. Summary judgment on a 45-day defense in the First Department requires an affidavit from someone who can describe the mail-intake procedure end to end — retrieval, opening, indexing, date-stamping, and file maintenance — plus the denial itself advising the provider of the right to submit reasonable justification. Skipping either step converts a winning defense into a triable issue of fact, or worse.

Practice Pointers

• Providers: demand the carrier’s mail-intake procedures in discovery, and compare the affiant’s job duties against the procedures described. An adjuster rarely works the mailroom.
• Providers: if a bill truly went out late, submit the reasonable justification in response to the denial — the regulation builds in that safety valve.
• Carriers: pair the adjuster’s affidavit with one from a mailroom or intake witness, and attach the date-stamped bill.
• Both sides: check the department. The First Department’s Appellate Term standard in SMB Med. is stricter than the Second’s, and motion strategy should follow venue.

Frequently Asked Questions

Do New York no-fault medical bills really have to be submitted within 45 days of treatment?

Yes. Under 11 NYCRR 65-1.1, written proof of claim must reach the carrier no later than 45 days after the date services are rendered. But the deadline is not absolute — the regulation allows late submissions to be excused upon reasonable justification, and the carrier’s denial must advise the provider of that opportunity.

How does an insurer prove a no-fault bill was submitted late?

The carrier must establish the date it received the bill. In the First Department, a conclusory affidavit stating a receipt date is insufficient; the affiant must describe the insurer’s regular practices for retrieving, opening, and indexing mail and maintaining claim files. Without that foundation, summary judgment on the 45-day defense fails.

What should a provider do if a no-fault claim is denied under the 45-day rule?

First, check whether the denial advised of the right to submit reasonable justification for the delay — and submit one if the facts support it. Second, scrutinize the carrier’s proof of the receipt date. If litigation follows, the carrier’s mailroom procedures are fair game in discovery.

Related Resources

• Mailing and proof of service: IME no-show — it was not mailed (Legal Encyclopedia hub)
• Browse the firm’s Legal Encyclopedia for the full no-fault claims timeline
• No-fault defense practice
• 45-day rule denial not sustianed
• 45-days…and then what?
• 45-day rule appeal was meritless