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Posted: March 9, 2014

Second Department Finds Private Right of Action Under Prompt Pay Law

On March 5, 2014, the Second Department issued a decision in Maimonides Medical Center v. First United American Life Insurance Co., 2014 NY Slip Op. 01441, examining whether there is a private right of action against insurers under Insurance Law § 3224-a (the Prompt Pay Law).

In Maimonides Medical Center, the Second Department held that a health care provider can assert claims against an insurer for violating Insurance Law § 3224-a, the Prompt Pay Law, which “sets forth time frames within which an insurer must either pay a claim, notify the claimant of the reason for denying a claim, or request additional information.” The court reasoned:

Where a statute does not expressly confer a private cause of action upon those it is intended to benefit, a private party may seek relief under the statute only if a legislative intent to create such a right of action is fairly implied in the statutory provisions and their legislative history. This inquiry involves three factors: (1) whether the plaintiff is one of the class for whose particular benefit the statute was enacted; (2) whether recognition of a private right of action would promote the legislative purpose; and (3) whether creation of such a right would be consistent with the legislative scheme.

Only the third factor, which is generally the most critical, is disputed here.

[The defendant] contends that the third factor has not been satisfied because private enforcement of the statute would be inconsistent with the legislative scheme, which delegates enforcement to the Superintendent. The amicus health plan organization agrees. This contention is not persuasive. We conclude that a private right of action, in addition to administrative enforcement, is fully consistent with the legislative scheme, and that a private right of action is to be implied.

No doubt there will be more litigation over this issue, which creates yet another basis for litigation against insurers.

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