Key Takeaway
Court ruling shows how healthcare providers can establish prima facie cases in no-fault insurance disputes by proving proper billing submission and insurer's failure to respond.
Understanding Prima Facie Cases in No-Fault Insurance Claims
In New York’s no-fault insurance system, healthcare providers must establish a prima facie case to recover payment for medical services. This means proving, at minimum, that they properly submitted billing forms and that the insurance company failed to pay or deny the claim within the statutory timeframe. A recent Second Department decision illustrates how the legal standards for establishing these cases have evolved over time.
The case demonstrates an important shift in what courts require to prove a prima facie case. While providers previously needed only to show they mailed billing forms and that 30 days had elapsed without payment, modern practice often requires additional proof regarding the insurer’s response—or lack thereof.
Jason Tenenbaum’s Analysis:
New York Hosp. Med. Ctr. of Queens v Allstate Ins. Co., 2014 NY Slip Op 00640 (2d Dept. 2014)
“The plaintiffs’ submissions included a postal receipt indicating that the prescribed NF-5 statutory billing form corresponding to the no-fault claim at issue, and related documents, were received by the defendant on May 26, 2011. The person who mailed the NF-5 form averred, in support of the plaintiffs’ motion, that the defendant neither paid nor properly denied the claim within 30 days. This initial showing was sufficient to demonstrate the plaintiffs’ prima facie entitlement to judgment as a matter of law on the first cause of action”
Here, Plaintiff mailed the billing and there was affirmative proof of lack of a proper denial. In the old days, Hospital would only have had shown mailing of the billing and 30-days elapsed.
Key Takeaway
This ruling highlights the evolution of prima facie case requirements in no-fault insurance litigation. Healthcare providers now benefit from including affirmative proof that insurers failed to properly respond to claims, rather than relying solely on proof of mailing and elapsed time. This approach strengthens prima facie cases and helps providers secure favorable judgments when denials are deficient.
