Source: https://www.sbglawny.com/court-of-appeals-addresses-plaintiffs-prima-facie-burden
Timestamp: 2019-04-18 22:51:56+00:00

Document:
In my Feb. 13, 2014, No-Fault Insurance Law Wrap-Up column,1 I reported on Viviane Etienne Medical Care v. Country-Wide Ins. Co.2 and the Appellate Division’s holding as to what is, and what is not, a no-fault plaintiff’s prima facie burden. The Court of Appeals subsequently granted leave to appeal, and on June 10, 2015, issued its decision, affirming, by a majority, the Appellate Division’s decision.3 A recap of the Appellate Division’s decision follows.
The plaintiff in that case, a medical provider office, moved for summary judgment, annexing to its motion copies of the bills in dispute and an affidavit of its third-party biller who averred that he prepared and mailed the plaintiff’s bills to the defendant insurer. The civil court denied plaintiff’s motion, finding plaintiff failed to satisfy its prima facie burden, and the plaintiff appealed. Citing Art of Healing,4 the Appellate Term affirmed, finding that plaintiff’s third-party biller “failed to demonstrate that he had personal knowledge of the plaintiff’s practices and procedures and that he was competent to testify about those practices and procedures.”5 Thus, the Appellate Term concluded, since the plaintiff failed to lay the proper business record foundation to admit the billing forms in evidence, it failed to meet its prima facie burden, and its motion was therefore properly denied.
The Appellate Division reversed, holding “the plaintiff established, prima facie, its entitlement to judgment as a matter of law by demonstrating that its prescribed statutory billing forms used to establish proof of claim (see 11 NYCRR 65-1.1) were mailed to and received by the defendant and that the defendant failed to either timely pay or deny the claims.”6Recognizing that its decision in Art of Healing Medicine v. Travelers Home & Mar. Ins. Co.,7 requiring a plaintiff to demonstrate the admissibility of its billing records under the business records exception to the hearsay rule, was “an anomaly, a jurisprudential drift,”8 the Appellate Division overruled Art of Healing.
In its appeal to the Court of Appeals, the defendant argued, inter alia, that plaintiff’s motion for summary judgment should have been denied because, although it was supported by the bills in question9 and by an affidavit from its third-party biller attesting to the mailing and to the insurer’s failure to pay or deny the bills, it was not supported by an affidavit from an individual with personal knowledge of the plaintiff medical provider office’s practices and procedures. Thus, according to the defendant, although the defendant was precluded from raising most defenses, such as lack of medical necessity or services not rendered, or otherwise challenging the veracity of the bills, the plaintiff failed to satisfy the business records exception of CPLR 4518 to admit the bills into evidence and therefore failed to satisfy its prima facie burden.
The plaintiff argued, inter alia, that consistent with decisions from the other judicial departments, as well as the Second Department prior to Art of Healing, the Appellate Division properly ruled that plaintiff satisfied its prima facie burden by establishing that its bills were mailed and neither paid nor denied. With respect to the argument that a summary judgment motion must be supported by admissible evidence, including an affidavit by a person with knowledge of the facts, plaintiff argued that the supporting affidavit of its biller was sufficient because he had personal knowledge of the submission of the bills.
Interestingly, Judge Pigott, who dissented in both Hospital for Joint Diseases v. Travelers Prop. Cas. Ins. Co.12 and Fair Price Med. Supply Corp. v. Travelers Indem. Co.13 and opined in those cases that the insurer who failed to timely deny or request additional verification was not precluded from challenging the validity of the assignment of benefits (Hospital for Joint Diseases) or raising a billing fraud defense (Fair Price) joined the majority’s opinion in Viviane Etienne that an insurer who fails to timely address a claim, whether by properly denying or requesting additional verification, will be precluded from challenging the bill later on in court.
CPLR 4518(a), the business record exception, provides, inter alia: “Any writing or record, whether in the form of an entry in a book or otherwise, made as a memorandum or record of any act, transaction, occurrence or event, shall be admissible in evidence in proof of that act, transaction, occurrence or event…” Thus, if it were plaintiff’s burden in the first instance to prove the “transaction, occurrence or event” contained in a verification of treatment form, i.e., that the services listed were performed on the date(s) listed, that the accident occurred, that the injuries sustained were causally related to the accident and that the services were medically necessary, for example, then an argument can be made that the plaintiff who offers the verification of treatment form into evidence to prove the contents therein must therefore satisfy a hearsay exception, such as the business record exception of CPLR 4518, to admit the verification of treatment form into evidence.
It is undisputed, however, that it is the defendant insurer’s burden to timely deny the claim to preserve its right to challenge the accuracy or validity of the contents of the verification of treatment form, and an insurer who fails to properly deny a claim is thus precluded from challenging the accuracy or validity of a bill or its contents. Therefore, it is argued, it cannot be plaintiff’s burden to prove the contents of the form as part of its prima facie case, and as the verification of treatment form is not offered to prove the “act, transaction, occurrence or event” contained in the claim form, the plaintiff need not satisfy the business record exception in CPLR 4518 regarding the verification of treatment form.
The decision finally puts to bed the issue of whether a plaintiff may rely upon a third-party biller’s affidavit to satisfy its prima facie burden.
See “Blockbuster Decision Changes The No-Fault Landscape (Again)” by David M. Barshay, NYLJ, Feb. 13, 2014.
114 A.D.3d 33 (2d Dept. 2013).
Viviane Etienne Med. Care v. Country-Wide Ins. Co., 25 N.Y.3d 498 (2015).
55 A.D.3d 644 (2d Dept. 2008).
2015 N.Y. Slip Op. 04787 (2015).
27 Misc.3d 141(A) (App Term 2d, 11th & 13th Jud Dists. 2010).
41 Misc.3d 140(A) (App Term 2d, 11th & 13th Jud Dists. 2013).
36 Misc.3d 135(A) (App Term 2d, 11th & 13th Jud Dists. 2012).
Presbyterian Hospital in the City of New York v. Maryland Casualty Company, 90 NY2d 274 at 285 (1997).
David M. Barshay is a member of The Sanders Law Firm, Garden City. Steven J. Neuwirth, a member of the firm, assisted in the preparation of this article.
© Copyright 2019 Sanders Barshay Grossman, LLC.

References: v. 
 v. 
 v. 
 v. 
 v. 
 v.