Key Takeaway
Appellate Division reverses trial court on no-fault insurance denial mailing practices and medical necessity evidence, establishing prima facie case standards.
AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C., 2016 NY Slip Op 00916 (2d Dept. 2016)
The reason I appealed
“Contrary to the Supreme Court’s determination, the affidavit of the plaintiff’s branch manager, submitted by the plaintiff in support of its motion for summary judgment, was sufficient to establish, prima facie, that its denial of claim forms were timely mailed in accordance with the plaintiff’s standard and appropriate office mailing practices and procedures (see Preferred Mut. Ins. Co. v Donnelly, 22 NY3d 1169; cf. Progressive Cas. Ins. Co. v Infinite Ortho Prods., Inc., 127 AD3d 1050, 1051). In opposition, the defendant failed to raise a triable issue of fact as to the timeliness of the denial of claim.”
Triable issue of fact – medical necessity
The medical necessity issue (first tine the Appellate Division, Second Department actually dealt with a Pan Chiro issue)
“Furthermore, with respect to the medical necessity of the services provided by the defendant, the plaintiff submitted affirmed medical evaluations which made a prima facie showing [*2]that the services at issue were not medically necessary (see Gaetane Physical Therapy, P.C. v Great N. Ins. Co., 47 Misc 3d 145, 2015 NY Slip Op 50698 ; Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co., 36 Misc 3d 153, 2012 NY Slip Op 51713 ).
However, in opposition to the motion, the defendants submitted affidavits and various medical records relating to Coyotl’s treatment which were sufficient to raise a triable issue of fact as to the necessity of that treatment (see Westcan Chiropractic, P.C. v Hertz Claim Mgt., 48 Misc 3d 133, 2015 NY Slip Op 51066 ; Lenox Hill Radiology & Mia, P.C. v Great N. Ins. Co., 47 Misc 3d 143, 2015 NY Slip Op 50680 ; Fine Healing Acupuncture, P.C. v Country-Wide Ins. Co., 33 Misc 3d 55 ).
Accordingly, the Supreme Court properly denied the plaintiff’s motion for summary judgment, as further proceedings are necessary to determine the issue of the medical necessity of the treatment rendered to Coyotl.”
Partial summary judgment
“urther proceedings are necessary to determine the issue of the medical necessity of the treatment rendered to Coyotl.”
I do not think I should have had costs awarded against me. I accomplished what needed to get done.
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- Be careful what you ask for: Discovery by summary judgment motion
- Mailing and the first time “objective” has landed in a medical rational case
- Understanding No-Fault Insurance Mailing Requirements: Lessons from the First Department’s “Venom” Decision
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2016 decision, New York Insurance Regulation 65-3.16(a)(5) and other sections of 11 NYCRR Part 65 governing no-fault insurance claim procedures may have been amended, particularly regarding mailing requirements, medical necessity determination procedures, and timeframes for denial notifications. Practitioners should verify current regulatory provisions and recent appellate decisions interpreting mailing standards and medical necessity evaluation requirements.
