What is a prima facie case? I still am unsure

Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 2013 NY Slip Op 08430 (2d Dept. 2013)(Rivera, Reinaldo, JP). (This one is about as long as a standard Federal Court opinion)

(1) “In this action by the plaintiff, a medical service provider, to recover first-party no-fault insurance benefits, this Court must address the issue of the plaintiff’s burden of proof on a motion for summary judgment in such an action.”  Interestingly, this does not discuss the proof at trial, where presumably there are timely denials.  Will a prima facie case now just be (a) proof of submission of the bill; and (b) proof that 30-days elapsed from submission and payment in full was not made?  If so, then the advantage of a first-department filing is now lost.

(2) “It follows that an insurer must also raise an objection regarding the bona fides of the plaintiff’s claim forms within the time schedules contained in the regulations. To conclude otherwise would permit an insurer to disregard the time windows set forth in the regulations and would countenance a belated evidentiary objection.”  The ability to actually contest the proof and fact of the loss is now lost when there is no proof of a timely disclaimer.  This makes sense, especially since “provider fraud”, although indictable is also precludable.

(3) Art of Healing has been cited by this Court on only one occasion (see Matter of Carothers v GEICO Indem. Co., 79 AD3d 864)…The Appellate Term has cited to Art of Healing on at least 99 occasions.”  It bears to note that the business records issue at the Appellate Term  only occurred when non-hospitals submitted no-fault billing.  The business records rule was perhaps a check or balance on providers that have a greater incidence, when compared to hospitals, of submitting bills that may not be wholly representative of the services they embody.

(4) “We now conclude that this Court’s holding in Art of Healing constitutes an anomaly, a jurisprudential drift from this Court’s well-established precedent.”  Was it really an anomaly?

(5) “What is a prima facie case”.  This is “proof of billing, namely, that the billing forms were mailed to and received by the defendant insurer, and that the insurer failed to either pay or deny the claim within the requisite 30-day period”  Now, must a provider that relies on proof of mailing also still assert that a timely denial has not been issued?  Or, does that prong of Ave T v. Auto One remain intact?  See Point 8 below.

(6) How is a prima facie case proved? “The “how” evidentiary component of the plaintiff’s proof is met by, inter alia, the affidavit of a billing agent or an employee of the medical provider; that is, someone with personal knowledge of the plaintiff’s billing methods.”

(7) “As part of its prima facie showing, the plaintiff is not required to show that the contents of the statutory no-fault forms themselves are accurate or that the medical services documented therein were actually rendered or necessary. Stated another way, the plaintiff is not required to establish the merits of the claim to meet its prima facie burden. To the extent that Art of Healing imposes a “business record” requirement obliging the plaintiff to establish the truth or the merits of the plaintiff’s claim, we overrule Art of Healing.”

(8) “If no denial of claim was proffered, a defendant insurer may avail itself of evidentiary objections, such as the business record exception to the rule against hearsay pursuant to CPLR 4518, only to challenge the plaintiff’s proof of billing relating to the mailing or receipt of the billing forms and the defendant’s alleged failure to deny or pay the claim within the requisite time periods.”  So, proof that a facially proper denial will defeat summary judgment.  Or, argument that Plaintiff failed to prove the absence of a denial will also defeat summary judgment,

(9) “However, with regard to the plaintiff’s claim [*7]dated November 17, 2004, in the amount of $139, we note that the plaintiff’s summary judgment motion papers included the defendant’s denial of that claim dated November 22, 2004. Contrary to the plaintiff’s contention, that denial of claim was, in fact, timely and sufficient (see Forrest Chen Acupuncture Servs., P.C. v GEICO Ins. Co., 54 AD3d 996, 996-997; Westchester Med. Ctr. v Allstate Ins. Co., 45 AD3d 579, 580). Therefore, as to that particular claim, the plaintiff did not meet its prima facie burden, and we need not consider the defendant’s opposition to that branch of the plaintiff’s motion.”  To me, this was the anomaly.  In certain cases, the App. Div. held that the inclusion of a timely denial causes a prima facie case not to be satisfied.  Now, this is settled law.

(10) “The defendant’s failure to timely request additional verification to establish proof of claim, object to the adequacy of the claim forms, or otherwise deny the claim precludes it from raising the instant defense; namely, that the plaintiff failed to demonstrate the admissibility of its claim forms under the business records exception to the rule against hearsay”.  So, the flip side is now that the inclusion of a timely denial now allows the carrier to object to the fact and amount of loss, requiring the provider to prove the merits of its claim?  How would this work?  Does an insurance carrier now assert a timely denial, without more causing the defense to be substantiated requiring a rebuttal case involving a business record foundation and now causing the carrier to put on its own rebuttal case involving the merits of the defense?

More questions have been asked than answered.

Related Articles

• Understanding CPLR 3212(a): Critical Timing Rules for Summary Judgment Motions in New York
• The CPLR 3212(g) paradigm
• No-Fault Verification Requirements: When Partial Compliance Isn’t Enough
• The amendments to the regulations and what they mean to you
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this post’s publication in 2013, New York’s no-fault insurance regulations have undergone several amendments, including updates to procedural requirements for prima facie case establishment and summary judgment standards in provider actions. Additionally, court interpretations of CPLR 4518 and the burden of proof requirements discussed in Viviane Etienne may have evolved through subsequent appellate decisions. Practitioners should verify current regulatory provisions and recent case law developments when establishing prima facie cases in no-fault litigation.