Another less than noteworthy prima facie decision

Prima facie case requirements in New York no-fault insurance litigation present persistent challenges for medical providers seeking payment for services rendered. The burden-shifting framework governing summary judgment motions requires plaintiffs to first establish that claims were timely submitted and remain unpaid beyond statutory deadlines. However, courts have divided sharply on what additional showings plaintiffs must make to satisfy their prima facie burden when carriers deny claims on substantive grounds such as lack of medical necessity, lack of coverage, or fraud.

The Appellate Division departments have articulated varying standards regarding whether plaintiffs must affirmatively demonstrate that denials lack merit to establish prima facie entitlement to judgment, or whether proof of timely submission and non-payment alone suffices to shift the burden to defendants. This circuit split creates significant practical consequences for litigation strategy, with some courts requiring minimal initial showings while others impose substantial evidentiary burdens on plaintiffs before defendants must respond.

Medical necessity denials occupy particularly contested terrain within prima facie case law. When carriers deny claims asserting that treatment was not medically necessary, must plaintiffs submit medical evidence establishing necessity as part of their prima facie case, or does the burden of proving lack of medical necessity rest entirely with defendants once plaintiffs show timely submission and non-payment? The resolution of this question fundamentally affects case outcomes and summary judgment success rates.

Case Background

In New York Diagnostic Medical Care, P.C. v GEICO General Insurance Co., the plaintiff medical provider sued to recover payment for services rendered to a patient injured in a motor vehicle accident. The plaintiff moved for summary judgment, submitting evidence that it had timely submitted claims to GEICO and that the carrier had not paid the claims within the statutory 30-day period. GEICO defended by denying the claims on grounds of lack of medical necessity.

The plaintiff’s motion papers did not include affirmative medical evidence establishing that the services provided were medically necessary. Instead, the plaintiff relied solely on proof of timely claim submission and non-payment to establish its prima facie case. The plaintiff argued that once it demonstrated unpaid, timely submitted claims, the burden shifted to GEICO to prove lack of medical necessity, and that plaintiffs bore no obligation to affirmatively demonstrate medical necessity as part of their initial prima facie showing.

GEICO cross-moved for summary judgment dismissing the complaint based on lack of medical necessity, submitting a peer review report concluding that the plaintiff’s services were not medically necessary. In opposition to GEICO’s cross-motion, the plaintiff submitted an affidavit from its treating doctor asserting that the services were medically necessary and explaining the clinical basis for that conclusion.

The Civil Court confronted the question whether the plaintiff had established a prima facie case sufficient to shift the burden to the defendant, or whether the plaintiff’s failure to address the merits of GEICO’s medical necessity denial in its initial motion papers defeated the prima facie case.

New York Diagnostic Med. Care, P.C. v GEICO Gen. Ins. Co., 2013 NY Slip Op 50419(U)(App. Term 2d Dept. 2013)

“Although plaintiff established that defendant had not paid the claim, plaintiff failed to show that the basis for the denial of the claim was conclusory, vague or lacked merit as a matter of law”

…

“In opposition to defendant’s cross motion for summary judgment dismissing the complaint on the ground of lack of medical necessity, plaintiff submitted an affidavit by its doctor which sufficiently demonstrated the existence of a question of fact as to medical necessity”

I know most of the judges in Queens and Kings refuse to follow the above line of cases regarding prima facie. Invariably, Plaintiff says that the Appellate Division, in some hospital case, said that proof of mailing of a bill and 30-days elapsing from mailing is sufficient to make a prima facie case, and the courts will find that sufficient. The cases then get appealed and reversed.

Putting aside certain realities, could this plaintiff have established his prima facie case through showing that the medical services were medically necessary? This would then show, until the burden shifted, that the denial lacks merit. Of course, Defendant through its peer review would have raise a triable issue o fact.

Legal Significance

The Appellate Term’s holding reinforces the heightened prima facie standard requiring plaintiffs to address the substantive merits of claim denials when moving for summary judgment. Under this framework, proof of timely submission and non-payment does not alone establish prima facie entitlement to judgment when carriers have denied claims on substantive grounds. Instead, plaintiffs must demonstrate that the denial bases “were conclusory, vague or lacked merit as a matter of law” to satisfy their prima facie burden.

This standard imposes significant initial burdens on plaintiffs beyond mere proof of non-payment. When carriers deny claims for lack of medical necessity, plaintiffs must submit medical evidence affirmatively establishing that services were medically necessary, or legal arguments demonstrating that the carrier’s denial was procedurally defective or legally insufficient. Generic assertions that denials lack merit fail to satisfy this burden without substantive evidence or analysis supporting those assertions.

The decision reflects judicial concern about perfunctory denials that carriers might issue without meaningful investigation or analysis. By requiring plaintiffs to show that denials were conclusory, vague, or legally insufficient, courts create incentives for carriers to issue substantive, detailed denial letters articulating specific factual and legal bases for claim denials. Carriers who issue generic, boilerplate denials risk plaintiffs satisfying their prima facie burden by demonstrating the denial’s inadequacy.

However, the second portion of the holding demonstrates that even when plaintiffs fail to establish prima facie cases, they may still defeat defendants’ cross-motions for summary judgment by raising triable issues of fact in opposition papers. Here, although the plaintiff failed to establish its prima facie case for summary judgment, the doctor’s affidavit submitted in opposition to the carrier’s cross-motion created factual questions regarding medical necessity that precluded summary judgment for either party.

This creates an asymmetric burden structure where plaintiffs must make substantial showings to obtain summary judgment but need only raise factual questions to defeat carriers’ summary judgment motions. Carriers seeking affirmative summary judgment dismissing claims must establish lack of medical necessity as a matter of law, while plaintiffs need only submit conflicting medical opinions to create triable issues precluding that relief.

Practical Implications

Medical providers moving for summary judgment in no-fault cases must include substantive analysis of carriers’ denial bases in their initial motion papers. When carriers deny claims for lack of medical necessity, plaintiffs should submit treating physician affidavits establishing medical necessity, explaining the clinical rationale for treatment, and addressing the specific concerns raised in carriers’ denials or peer reviews. Generic boilerplate affidavits asserting necessity without detailed clinical analysis may prove insufficient.

Alternatively, plaintiffs may establish prima facie cases by demonstrating procedural or legal deficiencies in denials themselves. If carriers issued denials after the 30-day statutory deadline, failed to comply with regulatory requirements for denial letters, or relied on defective peer reviews, plaintiffs can argue the denials lack legal merit without necessarily proving the substantive medical necessity of services. This approach requires careful analysis of Insurance Regulation 11 NYCRR § 65-3.8 requirements and case law establishing when denials fail to comply with procedural mandates.

Defense counsel should craft detailed, specific denial letters articulating concrete factual and legal bases for claim denials. Generic statements that services were “not medically necessary” without supporting analysis create vulnerability to arguments that denials were conclusory or vague. Peer review reports should address specific treatment modalities, explain clinical reasoning for necessity determinations, and cite relevant medical literature or guidelines supporting conclusions.

The decision also highlights the strategic value of cross-motions for summary judgment. Even when plaintiffs fail to establish prima facie cases entitling them to judgment, carriers who cross-move face their own heavy burdens to establish lack of medical necessity as a matter of law. Carriers rarely succeed on such cross-motions when plaintiffs submit conflicting medical opinions, making summary judgment a difficult remedy for either party in genuinely disputed medical necessity cases.

Practitioners in Kings and Queens counties note particular divergence between trial court practices and appellate standards in this area. Trial courts may grant summary judgment to plaintiffs based solely on proof of timely submission and non-payment, only to face reversal when defendants appeal citing decisions like New York Diagnostic Medical Care. Plaintiffs should anticipate this dynamic by making robust prima facie showings even in courts with reputations for accepting minimal evidence, protecting against appellate reversal and creating stronger negotiating positions.

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