Key Takeaway
Court ruling demonstrates how insurance companies waive their right to challenge claim form deficiencies if not raised during initial claims process.
Understanding Prima Facie Cases in No-Fault Insurance Claims
The concept of establishing a prima facie case in no-fault insurance litigation continues to evolve through appellate court decisions. A recent Second Department ruling in Nyack Hospital v. Allstate Insurance Co. provides important guidance on when insurance companies waive their right to challenge the adequacy of claim forms and how plaintiffs can establish their burden of proof.
This case highlights a fundamental principle in no-fault insurance law: timing matters. When insurers fail to raise procedural objections during the claims stage, they may find themselves precluded from asserting those same defenses later in litigation. The court’s analysis also demonstrates the relatively straightforward requirements for establishing a prima facie case when proper billing forms are submitted and the insurer fails to respond timely.
Jason Tenenbaum’s Analysis:
Nyack Hosp. v Allstate Ins. Co., 2014 NY Slip Op 00641 (2d Dept. 2014)
(1) “By failing to timely contest, at the claims stage, the adequacy of the claim forms used by the plaintiff Richmond University Medical Center, as assignee of Arnold Sealey, to establish proof of claim, the defendant waived its right to rely on any deficiencies in those forms at the litigation stage”
(2) “Accordingly, by submitting evidence in admissible form that the prescribed statutory billing form had been mailed to and received by the defendant insurer, which failed to either pay or deny the claim within the requisite 30-day period, the plaintiffs established their prima facie entitlement to judgment as a matter of law on the second cause of action”
I am wondering what deficiency Defendant raised. I also note that the Court again commented on this when it noted in passing that: “efendant does not contend on appeal that it raised a triable issue of fact in opposition to the plaintiffs’ prima facie showing, but only that the plaintiffs failed to meet their prima facie burden.” This Court is so hard to read sometimes through the innuendo that is at times used.
Key Takeaway
This decision reinforces that insurance companies must raise form deficiency objections during the initial claims process or risk waiving them entirely. Once proper billing forms are submitted and received without timely payment or denial, establishing a prima facie case becomes straightforward for healthcare providers seeking reimbursement.
