New York State Seal
STATE OF NEW YORK
INSURANCE DEPARTMENT
25 BEAVER STREET
NEW YORK, NEW YORK 10004

The Office of General Counsel issued the following informal opinion on February 4, 2002, representing the position of the New York State Insurance Department.

RE: No-Fault Arbitration: Decedent Healthcare Providers

Question:

May a party other than the legal representative of the estate of a deceased health care provider request No-Fault arbitration and receive reimbursement for disputed No-Fault claims for health services previously performed by the provider?

Conclusion:

Only the legal representative of the estate of a deceased provider, or an attorney retained by the legal representative to represent the decedent's estate, can request and pursue No-Fault arbitration and receive reimbursement for disputed claims for health services previously rendered by the provider.

Facts:

The wife of a deceased dental service provider, who is the named administrator of the provider’s estate, requested that a New York licensed dentist, who was not involved in the decedent’s dental practice, review and supervise the collection of payment for outstanding No-Fault claims for services previously rendered by the decedent provider. It is assumed that the decedent provider had received an assignment of benefits from the eligible injured person.

The New York licensed dentist inquired whether he could be appointed by the administrator of the estate to pursue arbitration for disputed claims in his own name, or whether the filing for arbitration and pursuit of disputed claims must be done by the administrator, or an attorney hired by the administrator, in the name of the deceased. The dentist also inquired as to whether there would be a different result were he to purchase the remaining practice of the deceased provider, or the accounts receivable of the practice, for collection purposes.

Analysis:

N.Y Comp. Codes R & Regs. tit. §65.12(1992) (Regulation 68) provides, in part:

(j) Direct payments. (1) An insurer shall pay benefits for any element of loss other than death benefits, directly to the applicant or, when appropriate, to the applicant’s parent or legal guardian or to any person legally responsible for necessities or, upon assignment by the applicant or any of the aforementioned persons, shall pay the providers of services or the applicant’s employer directly. Death benefits shall be paid to the estate of the eligible injured person.

In accordance with this provision, an assignment of benefits is limited to those from applicants (eligible injured persons) for No-Fault benefits to their provider of health services. A health service provider may not thereafter assign and transfer their rights to pursue and receive No-Fault benefits to any other third party, whether to another health service provider, collection agency or other business entity. Therefore, after assignment, the right to pursue and receive No-Fault benefits is limited solely to the assignee health service provider or attorney for that provider. The same limitation governs instances where the provider of services is deceased. In such instances, only the legal representative of the provider’s estate, or attorney retained by the legal representative on behalf of the estate, may pursue any rights or remedies relating to reimbursement for those health services previously rendered by the decedent provider.

Were another health provider to purchase the decedent’s remaining practice, it would not confer or transfer any right to the purchaser to pursue reimbursement for health services claims previously rendered by the decedent for No-Fault benefits which may be due and owing to the decedent’s estate.

For further information you may contact Supervising Attorney Lawrence M. Fuchsberg at the New York City Office.