Key Takeaway
A 2012 case shows how medical providers can lose no-fault summary judgment motions when their affidavits fail to clearly establish the insurer's denial was untimely or legally insufficient.
When Prima Facie Cases Fall Short: A Costly Mistake for Medical Providers
In New York’s no-fault insurance system, medical providers seeking payment must establish a strong prima facie case to succeed in court. This requires proving specific elements, including that the insurance company either failed to respond within 30 days or issued a deficient denial. However, as one 2012 case demonstrates, even experienced providers can stumble on these seemingly straightforward requirements.
The case of Complete Radiology, P.C. v Progressive Insurance Co. serves as a cautionary tale about the precision required in no-fault litigation. When providers fail to properly establish their prima facie case, they not only lose their chance at summary judgment but also face the prospect of costly arbitration proceedings. This outcome highlights why understanding the elements of a successful prima facie case is crucial for medical providers navigating the no-fault system.
Jason Tenenbaum’s Analysis:
Complete Radiology, P.C. v Progressive Ins. Co., 2012 NY Slip Op 50583(U)(App. Term 2d Dept. 2012)
“A no-fault provider establishes its prima facie entitlement to summary judgment by proof of the submission to the defendant of a claim form, proof of the fact and the amount of the loss sustained, and proof either that the defendant had failed to pay or deny the claim within the requisite 30-day period, or that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law (see Insurance Law § 5106 ; Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 ; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128, 2011 NY Slip Op 51292 ). Here, plaintiff’s affidavit failed to state unequivocally that defendant’s denial of claim forms were either untimely or without merit as a matter of law.”
Cases like this make AAA a lot of money.
Key Takeaway
Medical providers must be precise when establishing their prima facie case for summary judgment. Vague or ambiguous affidavits that fail to clearly state whether an insurer’s denial was untimely or legally deficient will result in the loss of summary judgment and force the case into expensive arbitration proceedings. Clear documentation about denial deficiencies is essential for success.
Legal Update (February 2026): Since this 2012 analysis, New York’s no-fault insurance regulations under Insurance Law § 5106 have undergone several amendments, including updates to claim submission procedures, denial response timeframes, and prima facie case requirements. Additionally, appellate decisions over the past decade have further refined the standards for establishing prima facie cases in no-fault litigation. Practitioners should verify current regulatory provisions and recent case law developments when advising clients on prima facie case strategies.
