Viviane Etienne Medical Care, P.C. v. Country-Wide Ins.
114 A.D.3d 33
| N.Y. App. Div. | 2013Background
- Plaintiff medical services provider sues insurer to recover no-fault benefits under Insurance Law § 5102.
- Issue is whether plaintiff must prove the merits of its claim at summary judgment as part of its prima facie case when no-fault claims were not timely denied.
- Court holds plaintiff need not prove merits; prima facie burden is proof of mailing the prescribed forms and overdue payment where insurer failed to pay or deny within 30 days.
- Plaintiff submitted NF-3 verification forms, NF-10 denial, and a Matatov affidavit describing mailing procedures and personal mailing oversight.
- Defendant challenged admissibility of forms as hearsay and sought to require business-record foundation under Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co.
- Appellate litigation proceeded, with Appellate Term upholding the earlier ruling that Art of Healing created an anomaly to be overruled; court overruled Art of Healing and granted summary judgment except for one $139 claim timely denied.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Prima facie burden in no-fault cases | Etienne asserted proof of mailing meets prima facie burden; no need to prove merits. | Country-Wide and Art of Healing require proving billing merits via admissible records. | Plaintiff need only show mailing and overdue payment; merits not required at this stage. |
| Effect of Art of Healing Medicine on burden | Art of Healing improperly added a 'merits' requirement to prima facie showing. | Art of Healing remains valid foundation rule for admissibility. | Art of Healing overruled; burden remains proof of mailing and overdue payment, not merits. |
| Preclusion vs. merits proof | Insurer failing to timely deny or request verification precludes objections to billing forms. | Preclusion should not relax plaintiff's ultimate burden to prove merits. | Insurer's failure to timely deny precludes evidentiary challenges to admissibility; plaintiff entitled to judgment on those claims except one. |
Key Cases Cited
- Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312 (2007) (timely denial required; 30-day payment rule central)
- Fair Price Med. Supply Corp. v Travelers Indem. Co., 10 NY3d 556 (2008) (preclusion remedy for fraud/defenses; tight timelines)
- Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 (1997) (premise of prompt, uncontested first-party benefits)
- Westchester Med. Ctr. v Progressive Cas. Ins. Co., 89 AD3d 1081 (2011) (prima facie proof by mailed forms plus overdue payment)
- Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co., 55 AD3d 644 (2008) (anomaly overruled; merits-admissibility requirement rejected)
- Matter of Carothers v GEICO Indem. Co., 79 AD3d 864 (2010) (prima facie proof requires admissible documentation of claimed loss)
- New York & Presbyt. Hosp. v Countrywide Ins. Co., 44 AD3d 729 (2007) (proof of mailing and overdue payment standard)
- New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 (2006) (recognizes mailing proof can support no-fault claim)