Key Takeaway
Analysis of New York Diagnostic Med. Care v GEICO decision on prima facie requirements in no-fault insurance claims and medical necessity standards.
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.
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