Preview
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 11/17/2023
EXHIBIT I
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 INSURANCE LAW
RECEIVED NYSCEF: 11/17/2023
NEW YORK MOTOR VEHICLE NO-FAULT
DENIAL OF CLAIM FORM
TO1NSURER: Complete this form, Including Item 33. Send 2 copies to appilcant. Upon the request of the injured person, the insurer
should send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the Injured person.
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-INSURER
MVAIC
100William Street14thPloor
New York NY 10038 For American Arbitration Assootation use
A. POLICYHOLDER B POLICY NUMBER C. DATE OF ACCIDENT 0------.EQNJ ED PERSON
06/06/2020 HAZEL, BRYAN
E. CLAIM NUMBER F. APPLICANT FOR BENEF1TS(Name and address) G. Als ASSIGNEE
One Point Acupuncture Po Yes a
182 8uffolk Rd No O
632899 Island Park, NY, 11558-
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO COf TEST THIS DENIAL
YOUAREADVISEDTHATFORREASONSNOTEDBELOW"
O 1. Your entire claim Is enied as follows: .
S 2. A portion of your clalrn is denied as follows:. .
O A. Loss of Eamings D. Interest $ $
B B. Health Service Benefite . .46.32 E. Attomey's Fee $ · $
$
O c. Other Necessary Expenses $ . .. F. Death Benefit $
. . REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below In Item 33)
POLICY ISSUES
Person'
O 3. Policy not in force on date of accident O 6. Injured person not an "Ellgible Injured
Π4. Injurgd person excluded under policy conditions O 7. Injuries did not arise out of use or operation of a
or exclusion motor vehicle
O 5. Policy conditione violated: O 8. Claim not within the scope of your election under
Optlanal Basic Economic Loss coverage
a. No reardohablejustification given for late
notice of claim
b. Reasonable justlfloatlon not established-- You
may qualify for speolai expedited arbitratiore
See page 2 of this form for instructions.
LOSS OF EARNINGS BENEFITS DENIED
O 9. Period of disability contested: period In dispute O 11. Exaggerated earnings clalm
From Through of $ per month denied
O 10. claimed loss not proven O 12, Statutory offset taken
O 13. Other, explained below
OTHER REASONABLE AND NECESSARY EXPENSES DEN1ED
O 14. Amount of ofalm exceeds dally limit of coverage O 16. Incurred after one year from date of accident
O 15. Unreasonable or unnecessary expenses O 17. Other, explained below
HEALTH SERVICE BENEFITS DENIED
. E 18. Fees not In accordance •Ith fee schedules O 20. Treatment not related to accident
O 19. È×cessive treatment, service or hospitalization O 21. Unnecessary treatment, service or hospitalization
From Through From Through
. 3 22, Other, explained below
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE IIENEFITS IS DENIED ..
23, Provider of Health Service (Name, Address and Zip Code) 25. Period of bill - treatment dates 29. Date f nal verific ion received
One Point Acupuncture PC . 09/09/2020 - 09/11/2020 05/03/ji 23
162 Suffolk Rd 26. Date of biU 30. ount of blH
Island Park, NY, 11558- 09/13/2020 $ 191.34
24. Type of service rendered 27. Date bIII received by Insurer 31 Amount pald by Ins rer
10/05/2020 $ 145.02
28. Date final verification requested 3 . Amount In disput
11/23/2020 $ 46.32
33. 8tate reason for denial, fully and explicitly (attach extra sheets11needed): COde 99201 is reduced to $33. 0 as the upuncture
fee for a Licensed Acupuncturist is adjusted to the chiropractic rate; All other charges paid i
D5/16/2023 Yu, Amanda 6482057834
DATE . Name and Title of Representative of Insurer Telephone No. & Ext.
Name and address of Insurer claim proceeshr (Third Party Administrator), if applicable Telephone No. & Ext.
NYS FORM NF-10 (Rev 1/2017)
Page 1 of 3
CC: HAZEL, BRYAN C/O
Michael Manoussos & Co PLLC
8002 Kew Gardens Rd, Ste 901
Kew Gardens , NY 11415
#
FILED: KINGS COUNTY NEW
CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
NYSCEF DOC. NO. 46 DENIAL oF CLAI FORM RECEIVED NYSCEF: 11/17/2023
TO INSURER: Cornplete this form, including item 33. Send 2 copies to appIlcant. Upon the request of the Injured person, the Insurer
namon
Ahnulrl Randto the inllimd nnrson Ononv of RIlnrannrihad nlalm for n and Hnnigmentssithmitterl hv ar nn hahalf nf the Inlurad
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-INSURER
MVAIC
100WilliamSt, 14thFloor
New York, NY 10038 For American Arbitration Association usa
B. POLICY NUMBER. C. DATE OF ACCIDENT D. INJURED PERSON
A. POLICYHOLDER
0U08/2020 . . 857
N1 5
E. CLAIM NUMBER F. APPIJCANT FOR BENEFITS (Name end address) G, AS ASS EE
.
Quantum Phyalcal therapy & Chlropractic Care PLLC Yes
No
632899 162 Suffolk Road
Island Park, NY, 11558- --
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CON) -ST THIS DENIAL
U AREADVISEDdHATFORREASONSNOTEDBELOW: .
1. Your entire claim le denied de follows:
2. ortion of your olajm le denied as follows
A. Loss of Eamings D. Interest $ $
B. Health Service Benefite . 15.38 E. Attorney's Fee $ $
$
F. Death Benefit . ' $
C Other Necessary Expenses $
REASON(S) FOR DENIAL OF CLAIM (Check reasone and explain below In Item 33)
POLICY I UES
Person'
3. Policy not In force on date of accident 6. Injured person not an "Ellglble Injured
4. injured person excluded under policy cond(tlons
U 7. InJmlesdid not arise out of use or operation of a
or excluaton . . . motor vehlole
5. 15olicyconditions violated: 8. Clalm not within the ecope of your election Under
. Optional Basic Economic Loss coverage
a. No reasonable justificatlan given for late
notice of ofalm
b Reasorïable Justification not established- You
arbitiation-
may quellfy for special expedited
See page 2 of this form for Instructions.
LOSS OF EARNINGS NEFITS DENIED
9. Period of disability contested: period In dlepute . 11. Exaggerated earninga claim
From Through of $ per month denied
10. ClaImed loss not proven U12. Statutory offset taken
13. Other, explained below
. OTHER REASONABLE AND NE SARY EXPENSES DENIED
16. Inourred after one year from date of accident
f4. Amount of claim exceeds daily limit of coverage
15. Unreasonable or unnecessary expenses 17. Other, explained below
HEALTH SERVICE B EFtTS DENIED
18. Fees not In accordance with fee schedules 20. Treatment not related to accident
. . 19. Excessive treatment, service or hospitalization 21. Unnecessary treatrnent, service or hospitalization
Ron1 Through From Through
22. Other, explained below
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DL NIED
23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill -treatment dates 29. Date I Ification
Quantum Physical Therapy & Chlropractic Care PLLC 09/09/2020 - 09/11/2020 receiv
05/0 023
162 Suffolk Road
26. Date of bill 3 /Amount of bill
island Park, NY, 11558-
09/13/2020 . 211.50
24. Type of service rendered 27. Date bill received by Insurer pt. Amount pald by. nsurer
09/28/2020 $ 196.12
Medleal .
28. Date final verification requested 32. Amount In dis to
. 11/16/2020_ . $ t S.38
33. State reason for denlal, fulty and explicitly (attach extra sheets If needed): SEE ATTACHED EOR
6 967834
05/09/2023 Yu, Ar·anda
Name and Title of Representative of insurer Telephone No. & Ext.
DATE
Telephone No. & Ext.
Name and address of Insurer claim processor (Third Party Administrator), If epplicable
NYS FORM NF-10 (Rev 1/2017)
Page 1 of 3
CC: HAZEL, BRYAN C/O
Michael Manousso8 & Co PLLC
8002 Kew Gardens Rd, Ste 901
Kew Gardens , NY 11415
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 11/17/2023
pEN)L OF CI IM FCPM
TO INSURER: Complete this form, including Item 33. Send 2 copies to applicant. Upon the request of the injured person, the Insurer
Rhouldannd to the inhamdnamon a nnny nf RIInrnandhad nIOImfn a and dnanmRntSRubmittedhv or on hnhOIfof thR InlUrAdDRFAnn
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-INSURER
MVAIC
100WiUtamSt, 14thFloor
New York, NY I0038 For American Arbh atlerrAssociatIan use
I 1 in
A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT LNJURED PER N
. 06/06/2020
HGN
. N11
E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G, AS AS E
Quantum Physical Therapy & Chiropractic Care PLLC Yes
632899 . 162 Suffolk Road
leland Park, NY, 11568- .
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CON1 ST THIS DENIAL
U AREADVISEOTHATFORREASONSNOTEDBELOW
1. Your entire claim Is denied as follows:
2. ortion of your claim.Is denied as follows:
A. Loss of Esmings $ D. Interest $ $
B. Health Service Benefits $ 75.19 E, Attorney's Fee $ $
C. Other Necessary Expenses $ F. Death Benefit $
REASO.N(S)FOR DENIAL OF CLAIM (Check reasons and explain below In Item 33)
POLICY I UES
3. Policy not In force on date of accident 6. Injured person not an "Ellglble injured Person'
4. injured person excluded urþer policy conditions 7. Injuries did not arlse out of use or operation of a
or exclusion motor vehicle
5. Poiley conditione violated: 8. Cialm not within the scope of your election under
Optional Basic Economic Loss coverage
a. No reasonable Justificailon given for late
notice of claim
b. Reasonable justification not established- You
may qualify for special expedited arbitration--
See page 2 of thfs form for Instructions.
LOSS OF EARNINGS NEPITS DENIED
9. Period of disabilhy contested: pedod in dispute 11. Exaggerated eaminge claim
From Through of $ per month denied
10. Claimed foss not proven 12. Statutory offset taken
13. Other, explained below
OTHER REASONABLE AND NE SARY EXPENSES DENIED
14. Amount of claim exceeds dally Ilmit of coverage 16. Incurred after one year from date of accident
15. Unreasonable or unnecessary expenses 17. Other, explained below
HEALTH SERVICE B NEFITS DENIED
18. Fees not In accordance wnh fee schedules 20. Treatment not related to accident
19. Excessive treatment, service or hospitalizatlan 21. Unnecessary treatment, servloe or hospitalization
From Through From Through
22. Other, explained below
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FrtR HEALTH SERVICE BENEFITS..IS D: NIED . ..3
23. Provider of Health Service (Name, Address and ZIP Code) 25. Period of bill - treatment dates 29. fina ve Ication
Quantum Physical Therapy & Chiropractic Care PLLC 09/15/2020 - 09/20/2020 rec d
162 Suffolk Road /P023
Island Park, NY, 11568, 26. Date of bill . Amount of bill
10/p3/2020 191.54
24. Type of servloe rendered 27. Date bill received by insurer 31. Amount pald b insurer
Medical 10/06/20P0 f S 116.35
28. Date final velificatIon requested 32. Amount In dls ute
11/23r2020 $ 75.19
33. State reason for denlaf, fully and explicitly (attach extra sheets If needed): SEE ATTACHED EOR
05/169023 Yµ Ama®da 46205, . 4
DATE Name and Title of Representative of Insurer Telephone No. & Ext.
Name and addrese of Insurer olaim processor (Third Party Adminlstrator), If applicable Telephone No. & Ext.
NYS FORM NF-10 (Rev 1/2017)
Page 1 of 3
CC: HAZEL, BRYAN C/O
Michael Manoussos & Co PLLC
8002 Kew Gardens Rd, Ste 901
Kew Gardens , NY 11415
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 11/17/2023
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
DENIAL OF CLAIM FORM
TO (NSURER: Complete this form, Including Item 33. Sand 2 coplee to applicant. Upon the request of the Injured person, the Insurer
should send to the Injured person a copy of ali prescribed claim forms and documente submitted by or on behalf of the Injured person.
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-INSURER
MVAIC
100WMiam Street14thF1cor
New York NY 10038 For American Arbitration Association use
A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON
06/06/2020 HAZEL, BRYAN
I
E, CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G. AS ASBJGNEE
. Quantum Physical Therapy & Chiropractic Care PLLC j yes g
162 Suffolk Road ! No
632899 island Park, NY, 11558-
TO APPLICANT: SEE REVÒRSE SIDE IF YOU WISH TO CONTEST THIS DENIAL
YOUAREADV)5EDTHATFORREASONSNOTEDBELQW:
O 1. YoW entire claim Is denied as follows:
E 2. A portion of yo.urolaim Is denied as follows:
O A. Loss of Earnings $ D. Interest $ $
E B. Health Service Benefile $ 10.92. ¤ E. Atlomey's Fee $ $
¤ C. Other Necessary Expenses $ . F. Death Benefit $
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below In Item 33)
POLICY ISSUES
Person"
O 3. Policy not In force on date of accident O 6. Injured person not an "Ellglble Injured
O 4. Injured person excluded under policy conditione O 7. injurles dki not arise out of use or operation of a
or excluelon motor shlcle
O 5. Policy conditione violated: O B. Cialm not within the scope of your election under
. Optiorial Basic Econornic Loss coverage
O a. No reasoIable Justifloationgiven for late
notice of clalin
O b. Reasonable juêtification not established-- You
·
may qualIfy for apecial expedited arbitration--
See page 2 of thIs form forinstructions.
LOSS OF EARNINGS BENEFITS DENIED
9. Period of disablflty contested: period In dispute 11. Exaggerated eamings claim
From . Through of $ per month denied
10. Ofarmed loes not proven 12. Statutory offset taken
13. Other, expla ned below
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
14. Amount of claim exceeds daily IImIt of coverage 16. Incurred after one year from date of accident
O 15, Unreasonable or unnecessary expenses 17. Other, explained below
HEALTH SERVICE BENEFITS DENIED
18. Fees not in accordance with fee schedules O 20. Treatment not related to accident
O 19, Excessive treatment, service or hospitalization O 21. Unnecessary treatment servlde or hospitalization
From Through From Through
. E 22. Other, explained below
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED
23. Provider of Health Servloe (Name, Address and Zip Code) 25. Period of bill -treatment dates 29. Dateºfin verification received
Quantum Phyelcal Therapy & Chiropractic Care PLLC 09/29/2020 - 10/06/2020 05/03/402•
182 Stiffolk Road 26. Date of bill 30. ount of b
lelarid Park; NYf 11558- 10/03/2020 $ 222.56
24. Type of service rendered 27. Date bill received by Insurer 3 . Amount pald Dy Insurer
10/28/2020 211.64
28. Date final verification requested E Amount In di pute
12/14/2020 10.92
33. State reason for denial, fully and explicitly (attach extra sheets If needed): DOS 9/29 PAID AT $46.24 AS RElid URSEME MAY NOT
EXCEED 8.0 RELATIVE VALUE UNITS WHEN MULTIPLE PHYSICAL MEDICINE PROCEDURES/MODALITI ARE P RFORMED ON
THE SAME DAY: ALL OTHER CHARGES PAID IN FULL.
-
0Éi/09/2023 Yu, Amanda 6482057834
DATE . . Name and Title of Representative of Insurer Telephone No. & Ext.
Name and address of Insurer claim processor (Third Party Administrator), If applicable Tetephone No. & Ext.
NYS FORM NF-10 (Rev 1/2017)
Page 1 of 3
CC: HAZEL, BRYAN C/O
Mich.ael Manoussos & Co PLLC
8002 Kew Gardens Rd, Ste 901
Kew Gardens , NY 11415
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 NEW YORK MOTOR VEMICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 11/17/2023
DENIA[. OF CLAN FORM
TO INSURER: Complete this form, Including Item 33. Send 2 copies to appileant. Upon the request of the Injured person, the Insurer
Rhnuld nand in the Ininrad narann a anrw nj all nrnanribedpinim fn a and dnnigmaniasighmfitedhv or on hahalf of the Inlumd narann
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-INSURER
MVAIC
100Wilham St, 14thFloor
New York, NY 10038 FC American Arbitration Association use
II
A. POLICYHOLDER 8. POLICY NUMBER C. DATE OF ACCIDENT . D. INJURED PERSON
06/06/2020 . N11- 1884
E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G. AS ASS EE
Quantum Physical Therapy & Chiropractic Care PLLC Yes
No
632899 162 Suffolk Road
island Park, NY, 11558-
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONT .ST THIS DENIAL
UAREADVISIED THATFORREASONSNOTEDBELOW:
t , Your entire claim Is denied as follows:
2. ortion of your claim Is denied as follows:
A. Loss of Earnings D. Interest $ $
B. Health Service Benefits . $ 53.83 E. Attomey's Fee $ $
C. Other Necessary Expenses $ F. Death Benefit $
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in Item 33)
POLICY I UES
3. Policy not In force on date of accident 6. Injured person not an "Ellgble Injured Person"
4. Injured person excluded under policy condit|ons 7. injuries did not arlee out of use or operation of a
or excluelon . .motor vehicle
5. Policy conditions violated 8. Claim not within the scope of your election under
Optional Basic Economic Loss coverage
a. No reasonable justiffoation given for late
notice of claim
b. Reasoliable justificarlon not established- You
may qualify for special expedIted arbitration-
O See page 2 of this form for instructions.
LOSS OF EARNINGS NEFITS DENIED
9. Period of disablflty contested: period In dispute 11. Exaggerated eaminge claim
From Through of $ per month denied
10. CIalmed losa not proven 12. Statutory offset taken
13. Other, explained below
OTHER REASONABLE AND NE SARY EXPENSES DENIED
Ï4. Amount of clarin exceede daily limit of coverage 16. Incurred after one year from date of accident
15. Unreasonable or unnecessary expenses 17. Other, explained below
HEALTH SERVICE B EFITS DENIED
18. Fees not In acconiance with fee schedules 20. Treatment not related to accident
19, Excessive treatment, service or hospitalization . 21. Unnecessary treatment, service cr hospitalization
From Through From Through
22. Other, explained below
COMPLETE ITEMS 23 THROUGH 32 IF CLAfM FOR HEALTH SERVICE BENEF1TSIS Di NIED
23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill -treatment dates 29. Date fi Lvedflijitt
Quantum Physical Therapy & Chiropractic Care PLLC 09/15/2020 - 08/29/2020 receiv
162 Suffolk Road . 0 023
Island Park, NY, 11558- 26. Date of bill 3 , Amount of bill
09/27/2020 485,03
24. Type'6f service rendered 27, Date blfl received by Insurer / 31. Amouni paid by insur
Medloal 10/07/2020 9 43t20
28. Date final verification requested 32. Amount In dispute
11/30/2020 $ 53.83
33. State reason for denlal, fully and explicitly (attach extra sheets if needed): SEE ATTACHED EOR
05/09/2093 Yu, Amagida 6462057834
DATE Name and Title of Representative of Insurer Telephone No. & ˆxt.
Name and address of Insurer claim processor (Third Party Administrator), 11applicable Telephone No. & Ext.
NYS FORM NF-10 (Rev 1/2017)
Page 1 of 3
CC: HAZEL, BRYAN O/O
Michael Manoussos & Co PLLC
8002 Kew Gardens Rd, Ste 901
Kew Gardens , NY 11415
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 11/17/2023
pENigL oF CLAMI FORM
TO INSURER: Complete this form, including item 33, Send 2 copies to applicant. Upon the request of the Injured person, the Insurer
shnuld-nand to the Inherndnarann a nnny of all nranorlhad alalm fn a and dnnumenta anhmitted hv or on hehalf of the Inhimd narann
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-lNSURER
MVAIC
100WEiam St, !4th Eloor
New York, NY 10038 . Fr American Arbitration AssocIntion.use
I
A. POLICYHOLDER B. POLfCY NUMBER C. DATE OF ACCtDENT D. INJURED PERSON
. . . 06/Ó6/202
. Ni1- iN5868
E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G. AS ASS EE
Quantum Physical Therapy & Chiropmetic Care PLLC yes
No
632899 162 Suffolk Road
... Island Park, NY, 11558-
--
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CON7 ST THIS DENIAL
U ARÉADVISEDTHAT ÒRREASONSNCrrEDBELOW: . .
1. Your entire claim le denied as follows:
2. ortion of your claini Is denied as follows:
A. Loss of Eamings $ D. Interest $ $
B. Health Service penefits $ 4.86 E. Attorney's Fee $ $
C. Other Necessary Expenses $ F. Death Benefit $
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below In item 33)
POLICY UES
3. Pofloy not in force on date of accident 6. fnfured person not an "Ellglbie Injured Person"
4. injured pWson excluded under paticy conditione 7. Injuries did not arlse out of use or operation of a
or excluelon motor vehicle
5. Polloy conditions violated: 8. Claim not within the scope of your election under
Optional Basic Economic Loss coverage
a. No reasonable Justificationgiven for ate
notice of clalm
b. Reseonable fustification noi established-- You
may qtiáIIfy for special espedited arbitration-
See page 2 of this form for instructions.
LOSS OF EARNINGS NEFITS DENIED
9. Period of disability contested: period in dispute 11. Exaggerated eamings claim
From Through of $ per month denied
10. Clajmed k)ss not proven 12. Statutory offset taken
13. Other, explained below
OTHER REASONABLE AND NE SARY EXPENSES DENIED -
14/Amount of claim exceeds dally Ilmit of coverage 16. IIdurred aftèr one year from date of accident
15. Unreasonable or unnecessary expenses 17. Other, explained below
HEALTH SERVICE B EFITS DENIED
18. Fees not In accordance with fee schedules 20. Treatment not refated to accident
19. Excessive treatment, estylce or hospitalization 21. Unnecessary treatment, service or hospitalization
.... From Through From Through
22. Other, explained below
.. COMPLETE ITEMS 23 THROlJ H 32 IF CLAIM R R HEALTH SERVICE BliNEFITS IS DI NIED .
23. Provider of Health Service (Name, Address and Zlp Code) 25. Period of bill - treatment dates 29. Date fi - · flon
Quantum Physical Therapy & Chlropractic Care PLLC 10/01/2020 - 10/06/2020 receiv
162 Suffolk Road Q 023
Island Park, NY, 11558. 26. Date of bill 3 . Amount of bill
10/13/2020 348. 6
24. Type of service rendered 27. Date bill received by Insurer 31. Amount paid by I urer
Medical 10/R0/2D20 343.²0
. 28. Date final verification.requested 32. Amount In disp
12/14/2020 $ 4.86
33. State reason for denial, fully and expilcitly (attach extra sheets If needed): SEE ATTACHED EOR
ori/09/8023 Yu NnqnrIs 646 57634
DATE Name and Title of Representallve of Insurer Telephone No. & Ext.
Name and address of Insurer claim processor (Third Party Administrator), If applicable Telephone No. & Ext.
NYS FORM NF-10 (Rev 1/2017)
Page 1 of 3
CC: HAZEL, BRYAN C/O
Michael Manoussos & Co PLLC
8002 Kew Gardens Rd, Ste 901
Kew Gardens , NY 11415
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023
NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 11/17/2023
NEW YOFIK MOTOR VEHICLE NO-FAULT INSURANCE LAW
Preview
FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 11/17/2023 EXHIBIT I FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 INSURANCE LAW RECEIVED NYSCEF: 11/17/2023 NEW YORK MOTOR VEHICLE NO-FAULT DENIAL OF CLAIM FORM TO1NSURER: Complete this form, Including Item 33. Send 2 copies to appilcant. Upon the request of the injured person, the insurer should send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the Injured person. NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-INSURER MVAIC 100William Street14thPloor New York NY 10038 For American Arbitration Assootation use A. POLICYHOLDER B POLICY NUMBER C. DATE OF ACCIDENT 0------.EQNJ ED PERSON 06/06/2020 HAZEL, BRYAN E. CLAIM NUMBER F. APPLICANT FOR BENEF1TS(Name and address) G. Als ASSIGNEE One Point Acupuncture Po Yes a 182 8uffolk Rd No O 632899 Island Park, NY, 11558- TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO COf TEST THIS DENIAL YOUAREADVISEDTHATFORREASONSNOTEDBELOW" O 1. Your entire claim Is enied as follows: . S 2. A portion of your clalrn is denied as follows:. . O A. Loss of Eamings D. Interest $ $ B B. Health Service Benefite . .46.32 E. Attomey's Fee $ · $ $ O c. Other Necessary Expenses $ . .. F. Death Benefit $ . . REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below In Item 33) POLICY ISSUES Person' O 3. Policy not in force on date of accident O 6. Injured person not an "Ellgible Injured Œ 4. Injurgd person excluded under policy conditions O 7. Injuries did not arise out of use or operation of a or exclusion motor vehicle O 5. Policy conditione violated: O 8. Claim not within the scope of your election under Optlanal Basic Economic Loss coverage a. No reardohablejustification given for late notice of claim b. Reasonable justlfloatlon not established-- You may qualify for speolai expedited arbitratiore See page 2 of this form for instructions. LOSS OF EARNINGS BENEFITS DENIED O 9. Period of disability contested: period In dispute O 11. Exaggerated earnings clalm From Through of $ per month denied O 10. claimed loss not proven O 12, Statutory offset taken O 13. Other, explained below OTHER REASONABLE AND NECESSARY EXPENSES DEN1ED O 14. Amount of ofalm exceeds dally limit of coverage O 16. Incurred after one year from date of accident O 15. Unreasonable or unnecessary expenses O 17. Other, explained below HEALTH SERVICE BENEFITS DENIED . E 18. Fees not In accordance •Ith fee schedules O 20. Treatment not related to accident O 19. È×cessive treatment, service or hospitalization O 21. Unnecessary treatment, service or hospitalization From Through From Through . 3 22, Other, explained below COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE IIENEFITS IS DENIED .. 23, Provider of Health Service (Name, Address and Zip Code) 25. Period of bill - treatment dates 29. Date f nal verific ion received One Point Acupuncture PC . 09/09/2020 - 09/11/2020 05/03/ji 23 162 Suffolk Rd 26. Date of biU 30. ount of blH Island Park, NY, 11558- 09/13/2020 $ 191.34 24. Type of service rendered 27. Date bIII received by Insurer 31 Amount pald by Ins rer 10/05/2020 $ 145.02 28. Date final verification requested 3 . Amount In disput 11/23/2020 $ 46.32 33. 8tate reason for denial, fully and explicitly (attach extra sheets11needed): COde 99201 is reduced to $33. 0 as the upuncture fee for a Licensed Acupuncturist is adjusted to the chiropractic rate; All other charges paid i D5/16/2023 Yu, Amanda 6482057834 DATE . Name and Title of Representative of Insurer Telephone No. & Ext. Name and address of Insurer claim proceeshr (Third Party Administrator), if applicable Telephone No. & Ext. NYS FORM NF-10 (Rev 1/2017) Page 1 of 3 CC: HAZEL, BRYAN C/O Michael Manoussos & Co PLLC 8002 Kew Gardens Rd, Ste 901 Kew Gardens , NY 11415 # FILED: KINGS COUNTY NEW CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW NYSCEF DOC. NO. 46 DENIAL oF CLAI FORM RECEIVED NYSCEF: 11/17/2023 TO INSURER: Cornplete this form, including item 33. Send 2 copies to appIlcant. Upon the request of the Injured person, the Insurer namon Ahnulrl Randto the inllimd nnrson Ononv of RIlnrannrihad nlalm for n and Hnnigmentssithmitterl hv ar nn hahalf nf the Inlurad NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-INSURER MVAIC 100WilliamSt, 14thFloor New York, NY 10038 For American Arbitration Association usa B. POLICY NUMBER. C. DATE OF ACCIDENT D. INJURED PERSON A. POLICYHOLDER 0U08/2020 . . 857 N1 5 E. CLAIM NUMBER F. APPIJCANT FOR BENEFITS (Name end address) G, AS ASS EE . Quantum Phyalcal therapy & Chlropractic Care PLLC Yes No 632899 162 Suffolk Road Island Park, NY, 11558- -- TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CON) -ST THIS DENIAL U AREADVISEDdHATFORREASONSNOTEDBELOW: . 1. Your entire claim le denied de follows: 2. ortion of your olajm le denied as follows A. Loss of Eamings D. Interest $ $ B. Health Service Benefite . 15.38 E. Attorney's Fee $ $ $ F. Death Benefit . ' $ C Other Necessary Expenses $ REASON(S) FOR DENIAL OF CLAIM (Check reasone and explain below In Item 33) POLICY I UES Person' 3. Policy not In force on date of accident 6. Injured person not an "Ellglble Injured 4. injured person excluded under policy cond(tlons U 7. InJmlesdid not arise out of use or operation of a or excluaton . . . motor vehlole 5. 15olicyconditions violated: 8. Clalm not within the ecope of your election Under . Optional Basic Economic Loss coverage a. No reasonable justificatlan given for late notice of ofalm b Reasorïable Justification not established- You arbitiation- may quellfy for special expedited See page 2 of this form for Instructions. LOSS OF EARNINGS NEFITS DENIED 9. Period of disability contested: period In dlepute . 11. Exaggerated earninga claim From Through of $ per month denied 10. ClaImed loss not proven U12. Statutory offset taken 13. Other, explained below . OTHER REASONABLE AND NE SARY EXPENSES DENIED 16. Inourred after one year from date of accident f4. Amount of claim exceeds daily limit of coverage 15. Unreasonable or unnecessary expenses 17. Other, explained below HEALTH SERVICE B EFtTS DENIED 18. Fees not In accordance with fee schedules 20. Treatment not related to accident . . 19. Excessive treatment, service or hospitalization 21. Unnecessary treatrnent, service or hospitalization Ron1 Through From Through 22. Other, explained below COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DL NIED 23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill -treatment dates 29. Date I Ification Quantum Physical Therapy & Chlropractic Care PLLC 09/09/2020 - 09/11/2020 receiv 05/0 023 162 Suffolk Road 26. Date of bill 3 /Amount of bill island Park, NY, 11558- 09/13/2020 . 211.50 24. Type of service rendered 27. Date bill received by Insurer pt. Amount pald by. nsurer 09/28/2020 $ 196.12 Medleal . 28. Date final verification requested 32. Amount In dis to . 11/16/2020_ . $ t S.38 33. State reason for denlal, fulty and explicitly (attach extra sheets If needed): SEE ATTACHED EOR 6 967834 05/09/2023 Yu, Ar·anda Name and Title of Representative of insurer Telephone No. & Ext. DATE Telephone No. & Ext. Name and address of Insurer claim processor (Third Party Administrator), If epplicable NYS FORM NF-10 (Rev 1/2017) Page 1 of 3 CC: HAZEL, BRYAN C/O Michael Manousso8 & Co PLLC 8002 Kew Gardens Rd, Ste 901 Kew Gardens , NY 11415 FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 11/17/2023 pEN)L OF CI IM FCPM TO INSURER: Complete this form, including Item 33. Send 2 copies to applicant. Upon the request of the injured person, the Insurer Rhouldannd to the inhamdnamon a nnny nf RIInrnandhad nIOImfn a and dnanmRntSRubmittedhv or on hnhOIfof thR InlUrAdDRFAnn NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-INSURER MVAIC 100WiUtamSt, 14thFloor New York, NY I0038 For American Arbh atlerrAssociatIan use I 1 in A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT LNJURED PER N . 06/06/2020 HGN . N11 E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G, AS AS E Quantum Physical Therapy & Chiropractic Care PLLC Yes 632899 . 162 Suffolk Road leland Park, NY, 11568- . TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CON1 ST THIS DENIAL U AREADVISEOTHATFORREASONSNOTEDBELOW 1. Your entire claim Is denied as follows: 2. ortion of your claim.Is denied as follows: A. Loss of Esmings $ D. Interest $ $ B. Health Service Benefits $ 75.19 E, Attorney's Fee $ $ C. Other Necessary Expenses $ F. Death Benefit $ REASO.N(S)FOR DENIAL OF CLAIM (Check reasons and explain below In Item 33) POLICY I UES 3. Policy not In force on date of accident 6. Injured person not an "Ellglble injured Person' 4. injured person excluded urþer policy conditions 7. Injuries did not arlse out of use or operation of a or exclusion motor vehicle 5. Poiley conditione violated: 8. Cialm not within the scope of your election under Optional Basic Economic Loss coverage a. No reasonable Justificailon given for late notice of claim b. Reasonable justification not established- You may qualify for special expedited arbitration-- See page 2 of thfs form for Instructions. LOSS OF EARNINGS NEPITS DENIED 9. Period of disabilhy contested: pedod in dispute 11. Exaggerated eaminge claim From Through of $ per month denied 10. Claimed foss not proven 12. Statutory offset taken 13. Other, explained below OTHER REASONABLE AND NE SARY EXPENSES DENIED 14. Amount of claim exceeds dally Ilmit of coverage 16. Incurred after one year from date of accident 15. Unreasonable or unnecessary expenses 17. Other, explained below HEALTH SERVICE B NEFITS DENIED 18. Fees not In accordance wnh fee schedules 20. Treatment not related to accident 19. Excessive treatment, service or hospitalizatlan 21. Unnecessary treatment, servloe or hospitalization From Through From Through 22. Other, explained below COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FrtR HEALTH SERVICE BENEFITS..IS D: NIED . ..3 23. Provider of Health Service (Name, Address and ZIP Code) 25. Period of bill - treatment dates 29. fina ve Ication Quantum Physical Therapy & Chiropractic Care PLLC 09/15/2020 - 09/20/2020 rec d 162 Suffolk Road /P023 Island Park, NY, 11568, 26. Date of bill . Amount of bill 10/p3/2020 191.54 24. Type of servloe rendered 27. Date bill received by insurer 31. Amount pald b insurer Medical 10/06/20P0 f S 116.35 28. Date final velificatIon requested 32. Amount In dls ute 11/23r2020 $ 75.19 33. State reason for denlaf, fully and explicitly (attach extra sheets If needed): SEE ATTACHED EOR 05/169023 Yµ Ama®da 46205, . 4 DATE Name and Title of Representative of Insurer Telephone No. & Ext. Name and addrese of Insurer olaim processor (Third Party Adminlstrator), If applicable Telephone No. & Ext. NYS FORM NF-10 (Rev 1/2017) Page 1 of 3 CC: HAZEL, BRYAN C/O Michael Manoussos & Co PLLC 8002 Kew Gardens Rd, Ste 901 Kew Gardens , NY 11415 FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 11/17/2023 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW DENIAL OF CLAIM FORM TO (NSURER: Complete this form, Including Item 33. Sand 2 coplee to applicant. Upon the request of the Injured person, the Insurer should send to the Injured person a copy of ali prescribed claim forms and documente submitted by or on behalf of the Injured person. NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-INSURER MVAIC 100WMiam Street14thF1cor New York NY 10038 For American Arbitration Association use A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON 06/06/2020 HAZEL, BRYAN I E, CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G. AS ASBJGNEE . Quantum Physical Therapy & Chiropractic Care PLLC j yes g 162 Suffolk Road ! No 632899 island Park, NY, 11558- TO APPLICANT: SEE REVÒRSE SIDE IF YOU WISH TO CONTEST THIS DENIAL YOUAREADV)5EDTHATFORREASONSNOTEDBELQW: O 1. YoW entire claim Is denied as follows: E 2. A portion of yo.urolaim Is denied as follows: O A. Loss of Earnings $ D. Interest $ $ E B. Health Service Benefile $ 10.92. ¤ E. Atlomey's Fee $ $ ¤ C. Other Necessary Expenses $ . F. Death Benefit $ REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below In Item 33) POLICY ISSUES Person" O 3. Policy not In force on date of accident O 6. Injured person not an "Ellglble Injured O 4. Injured person excluded under policy conditione O 7. injurles dki not arise out of use or operation of a or excluelon motor shlcle O 5. Policy conditione violated: O B. Cialm not within the scope of your election under . Optiorial Basic Econornic Loss coverage O a. No reasoIable Justifloationgiven for late notice of clalin O b. Reasonable juêtification not established-- You · may qualIfy for apecial expedited arbitration-- See page 2 of thIs form forinstructions. LOSS OF EARNINGS BENEFITS DENIED 9. Period of disablflty contested: period In dispute 11. Exaggerated eamings claim From . Through of $ per month denied 10. Ofarmed loes not proven 12. Statutory offset taken 13. Other, expla ned below OTHER REASONABLE AND NECESSARY EXPENSES DENIED 14. Amount of claim exceeds daily IImIt of coverage 16. Incurred after one year from date of accident O 15, Unreasonable or unnecessary expenses 17. Other, explained below HEALTH SERVICE BENEFITS DENIED 18. Fees not in accordance with fee schedules O 20. Treatment not related to accident O 19, Excessive treatment, service or hospitalization O 21. Unnecessary treatment servlde or hospitalization From Through From Through . E 22. Other, explained below COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED 23. Provider of Health Servloe (Name, Address and Zip Code) 25. Period of bill -treatment dates 29. Dateºfin verification received Quantum Phyelcal Therapy & Chiropractic Care PLLC 09/29/2020 - 10/06/2020 05/03/402• 182 Stiffolk Road 26. Date of bill 30. ount of b lelarid Park; NYf 11558- 10/03/2020 $ 222.56 24. Type of service rendered 27. Date bill received by Insurer 3 . Amount pald Dy Insurer 10/28/2020 211.64 28. Date final verification requested E Amount In di pute 12/14/2020 10.92 33. State reason for denial, fully and explicitly (attach extra sheets If needed): DOS 9/29 PAID AT $46.24 AS RElid URSEME MAY NOT EXCEED 8.0 RELATIVE VALUE UNITS WHEN MULTIPLE PHYSICAL MEDICINE PROCEDURES/MODALITI ARE P RFORMED ON THE SAME DAY: ALL OTHER CHARGES PAID IN FULL. - 0Éi/09/2023 Yu, Amanda 6482057834 DATE . . Name and Title of Representative of Insurer Telephone No. & Ext. Name and address of Insurer claim processor (Third Party Administrator), If applicable Tetephone No. & Ext. NYS FORM NF-10 (Rev 1/2017) Page 1 of 3 CC: HAZEL, BRYAN C/O Mich.ael Manoussos & Co PLLC 8002 Kew Gardens Rd, Ste 901 Kew Gardens , NY 11415 FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 NEW YORK MOTOR VEMICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 11/17/2023 DENIA[. OF CLAN FORM TO INSURER: Complete this form, Including Item 33. Send 2 copies to appileant. Upon the request of the Injured person, the Insurer Rhnuld nand in the Ininrad narann a anrw nj all nrnanribedpinim fn a and dnnigmaniasighmfitedhv or on hahalf of the Inlumd narann NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-INSURER MVAIC 100Wilham St, 14thFloor New York, NY 10038 FC American Arbitration Association use II A. POLICYHOLDER 8. POLICY NUMBER C. DATE OF ACCIDENT . D. INJURED PERSON 06/06/2020 . N11- 1884 E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G. AS ASS EE Quantum Physical Therapy & Chiropractic Care PLLC Yes No 632899 162 Suffolk Road island Park, NY, 11558- TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONT .ST THIS DENIAL UAREADVISIED THATFORREASONSNOTEDBELOW: t , Your entire claim Is denied as follows: 2. ortion of your claim Is denied as follows: A. Loss of Earnings D. Interest $ $ B. Health Service Benefits . $ 53.83 E. Attomey's Fee $ $ C. Other Necessary Expenses $ F. Death Benefit $ REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in Item 33) POLICY I UES 3. Policy not In force on date of accident 6. Injured person not an "Ellgble Injured Person" 4. Injured person excluded under policy condit|ons 7. injuries did not arlee out of use or operation of a or excluelon . .motor vehicle 5. Policy conditions violated 8. Claim not within the scope of your election under Optional Basic Economic Loss coverage a. No reasonable justiffoation given for late notice of claim b. Reasoliable justificarlon not established- You may qualify for special expedIted arbitration- O See page 2 of this form for instructions. LOSS OF EARNINGS NEFITS DENIED 9. Period of disablflty contested: period In dispute 11. Exaggerated eaminge claim From Through of $ per month denied 10. CIalmed losa not proven 12. Statutory offset taken 13. Other, explained below OTHER REASONABLE AND NE SARY EXPENSES DENIED Ï4. Amount of clarin exceede daily limit of coverage 16. Incurred after one year from date of accident 15. Unreasonable or unnecessary expenses 17. Other, explained below HEALTH SERVICE B EFITS DENIED 18. Fees not In acconiance with fee schedules 20. Treatment not related to accident 19, Excessive treatment, service or hospitalization . 21. Unnecessary treatment, service cr hospitalization From Through From Through 22. Other, explained below COMPLETE ITEMS 23 THROUGH 32 IF CLAfM FOR HEALTH SERVICE BENEF1TSIS Di NIED 23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill -treatment dates 29. Date fi Lvedflijitt Quantum Physical Therapy & Chiropractic Care PLLC 09/15/2020 - 08/29/2020 receiv 162 Suffolk Road . 0 023 Island Park, NY, 11558- 26. Date of bill 3 , Amount of bill 09/27/2020 485,03 24. Type'6f service rendered 27, Date blfl received by Insurer / 31. Amouni paid by insur Medloal 10/07/2020 9 43t20 28. Date final verification requested 32. Amount In dispute 11/30/2020 $ 53.83 33. State reason for denlal, fully and explicitly (attach extra sheets if needed): SEE ATTACHED EOR 05/09/2093 Yu, Amagida 6462057834 DATE Name and Title of Representative of Insurer Telephone No. & ˆxt. Name and address of Insurer claim processor (Third Party Administrator), 11applicable Telephone No. & Ext. NYS FORM NF-10 (Rev 1/2017) Page 1 of 3 CC: HAZEL, BRYAN O/O Michael Manoussos & Co PLLC 8002 Kew Gardens Rd, Ste 901 Kew Gardens , NY 11415 FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW RECEIVED NYSCEF: 11/17/2023 pENigL oF CLAMI FORM TO INSURER: Complete this form, including item 33, Send 2 copies to applicant. Upon the request of the Injured person, the Insurer shnuld-nand to the Inherndnarann a nnny of all nranorlhad alalm fn a and dnnumenta anhmitted hv or on hehalf of the Inhimd narann NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-lNSURER MVAIC 100WEiam St, !4th Eloor New York, NY 10038 . Fr American Arbitration AssocIntion.use I A. POLICYHOLDER B. POLfCY NUMBER C. DATE OF ACCtDENT D. INJURED PERSON . . . 06/Ó6/202 . Ni1- iN5868 E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and address) G. AS ASS EE Quantum Physical Therapy & Chiropmetic Care PLLC yes No 632899 162 Suffolk Road ... Island Park, NY, 11558- -- TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CON7 ST THIS DENIAL U ARÉADVISEDTHAT ÒRREASONSNCrrEDBELOW: . . 1. Your entire claim le denied as follows: 2. ortion of your claini Is denied as follows: A. Loss of Eamings $ D. Interest $ $ B. Health Service penefits $ 4.86 E. Attorney's Fee $ $ C. Other Necessary Expenses $ F. Death Benefit $ REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below In item 33) POLICY UES 3. Pofloy not in force on date of accident 6. fnfured person not an "Ellglbie Injured Person" 4. injured pWson excluded under paticy conditione 7. Injuries did not arlse out of use or operation of a or excluelon motor vehicle 5. Polloy conditions violated: 8. Claim not within the scope of your election under Optional Basic Economic Loss coverage a. No reasonable Justificationgiven for ate notice of clalm b. Reseonable fustification noi established-- You may qtiáIIfy for special espedited arbitration- See page 2 of this form for instructions. LOSS OF EARNINGS NEFITS DENIED 9. Period of disability contested: period in dispute 11. Exaggerated eamings claim From Through of $ per month denied 10. Clajmed k)ss not proven 12. Statutory offset taken 13. Other, explained below OTHER REASONABLE AND NE SARY EXPENSES DENIED - 14/Amount of claim exceeds dally Ilmit of coverage 16. IIdurred aftèr one year from date of accident 15. Unreasonable or unnecessary expenses 17. Other, explained below HEALTH SERVICE B EFITS DENIED 18. Fees not In accordance with fee schedules 20. Treatment not refated to accident 19. Excessive treatment, estylce or hospitalization 21. Unnecessary treatment, service or hospitalization .... From Through From Through 22. Other, explained below .. COMPLETE ITEMS 23 THROlJ H 32 IF CLAIM R R HEALTH SERVICE BliNEFITS IS DI NIED . 23. Provider of Health Service (Name, Address and Zlp Code) 25. Period of bill - treatment dates 29. Date fi - · flon Quantum Physical Therapy & Chlropractic Care PLLC 10/01/2020 - 10/06/2020 receiv 162 Suffolk Road Q 023 Island Park, NY, 11558. 26. Date of bill 3 . Amount of bill 10/13/2020 348. 6 24. Type of service rendered 27. Date bill received by Insurer 31. Amount paid by I urer Medical 10/R0/2D20 343.²0 . 28. Date final verification.requested 32. Amount In disp 12/14/2020 $ 4.86 33. State reason for denial, fully and expilcitly (attach extra sheets If needed): SEE ATTACHED EOR ori/09/8023 Yu NnqnrIs 646 57634 DATE Name and Title of Representallve of Insurer Telephone No. & Ext. Name and address of Insurer claim processor (Third Party Administrator), If applicable Telephone No. & Ext. NYS FORM NF-10 (Rev 1/2017) Page 1 of 3 CC: HAZEL, BRYAN C/O Michael Manoussos & Co PLLC 8002 Kew Gardens Rd, Ste 901 Kew Gardens , NY 11415 FILED: KINGS COUNTY CLERK 11/17/2023 12:20 PM INDEX NO. 505667/2023 NYSCEF DOC. NO. 46 RECEIVED NYSCEF: 11/17/2023 NEW YOFIK MOTOR VEHICLE NO-FAULT INSURANCE LAW