Key Takeaway
Court reaffirms essential elements of prima facie case in no-fault insurance claims, emphasizing medical providers must prove denial issues beyond just non-payment.
Understanding Prima Facie Requirements in No-Fault Insurance Claims
In no-fault insurance litigation, medical providers must establish specific elements to succeed in their claims for unpaid benefits. A recent Appellate Term decision reinforces the fundamental requirements that providers must meet when seeking summary judgment, particularly regarding the handling of claim denials by insurance companies.
The case of J.C. Healing Touch Rehab, P.C. v Amica Mutual Insurance Company serves as an important reminder that simply proving non-payment within 30 days is insufficient to establish a prima facie case. Medical providers must go further and demonstrate specific deficiencies in the insurance company’s response to their claims.
Jason Tenenbaum’s Analysis:
J.C. Healing Touch Rehab, P.C. v Amica Mut. Ins. Co., 2014 NY Slip Op 50969(U)(App. Term 2d Dept. 2014)
“While the supporting affidavit by plaintiff’s billing agent established that plaintiff had mailed the claim forms in question to defendant, and that defendant had failed to pay those claims within the requisite 30-day period, the affidavit failed to demonstrate either that defendant had failed to deny the claims within the requisite 30-day period or that defendant had issued timely denial of claim forms which were conclusory, vague or without merit as a matter of law. As plaintiff failed to meet its initial burden of establishing its prima facie entitlement to judgment as a matter of law, plaintiff’s motion for summary judgment was properly denied (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33).”
The medical provider still needs to allege that it never received a denial, the denial was untimely, or the received denial is defective. Etienne did not change that part of Plaintiff’s prima facie case.
Key Takeaway
Medical providers pursuing no-fault claims must prove more than just non-payment within 30 days. They must establish that the insurance company either failed to issue a timely denial, provided no denial at all, or issued a defective denial. This requirement remains unchanged despite evolving case law in this area of practice.
