37 Misc. 3d 19
N.Y. App. Term.2012Background
- Plaintiff-provider sues to recover assigned first-party no-fault benefits for medical supplies.
- Civil Court limited trial to whether supplies were medically necessary; at nonjury trial, defendant offered Dr. Corcoran’s testimony based on a peer review report.
- Corcoran relied on medical records and other documents (claim form admitted; medical records excluded) to form her opinion.
- The court sustained objections to admitting medical records; defendant sought admission again but was denied, and plaintiff obtained judgment for the full amount.
- Court issues decision: medical records should have been admitted to enable Corcoran to testify; reversed and remitted for new trial.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Admissibility of medical records | Defendant must prove facts itself; records are not admissible hearsay-based proof. | Medical records are admissible to provide the factual basis for expert opinion on medical necessity if properly authenticated. | Medical records should have been admitted; error to exclude them. |
| Use of records to prove medical necessity defense | Plaintiff contends records cannot be used to establish lack of medical necessity. | Insurer may rely on records to deny based on lack of necessity without proving injuries. | Records may be used to support the defense; insurer may deny based on presumed facts from records. |
| Burden-shifting in no-fault medical-necessity defense | Plaintiff argues defendant need not prove underlying facts beyond the records. | Defendant should be permitted to present expert opinion based on the records to prove lack of medical necessity. | Burden appropriately shifts to defendant to prove lack of medical necessity with admissible evidence once records are admitted. |
Key Cases Cited
- Hambsch v. New York City Tr. Auth., 63 N.Y.2d 723 (1984) (limits on reliance on out-of-court medical records for proving injuries)
- Wagman v. Bradshaw, 292 A.D.2d 84 (2002) (out-of-court records not controlling for medical-necessity determinations)
- Zeldin v. Interboro Mut. Indent. Ins. Co., 44 A.D.3d 652 (2007) (assignor’s shoes standard for standing to claim benefits)
- Quiroa v. Ferenczi, 77 A.D.3d 901 (2010) (records used to show information conveyed to insurer, not to prove injury fact)
- Gelpi v. 37th Ave. Realty Corp., 281 A.D.2d 392 (2001) (use of medical documentation to establish information conveyed to insurer)