Key Takeaway
Court case refines prima facie requirements for no-fault insurance claims, clarifying medical providers don't need business records exception proof in NY.
New York Hosp. Med. Ctr. of Queens v QBE Ins. Corp**.**, 2014 NY Slip Op 00639 (2d Dept. 2014)
“The plaintiffs made a prima facie showing of entitlement to judgment as a matter of law on the second cause of action, which related to the claim submitted by Westchester Medical Center in connection with the injuries allegedly sustained by its assignor, Robert de los Santos, by submitting evidence that the prescribed statutory billing form had been mailed to and received by the defendant insurer, which failed to either pay or deny the claims within the requisite 30-day period (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co.,AD3d, 2013 NY Slip Op 08430 ;Westchester Med. Ctr. v Hereford Ins. Co., 95 AD3d 1306, 1306-1307; Westchester Med. Ctr. v Lancer Ins. Co., 94 AD3d 984, 984; Westchester Med. Ctr. v Progressive Cas. Ins. Co., 89 AD3d 1081, 1082). A medical provider is not required, as part of its prima facie showing, to demonstrate the admissibility of its billing records or to prove the truth of their content under the business records exception to the hearsay rule (see CPLR 4518; Viviane [*2]Etienne Med. Care, P.C. v Country-Wide Ins. Co.,AD3d, 2013 NY Slip Op 08430, *6 ). In opposition to the plaintiffs’ showing in connection with the second cause of action, the defendant failed to raise a triable issue of fact as to whether it properly requested further verification of that claim”
Again, note that this new formulation of a prima facie stands true to the Westchester v. Liberty rule that the medical provider must prove the absence of a timely denial, the defective nature of the denial, or the affirmative merits of the claim, e.g.., the services were medically necessary, the EIP showed up to the IME, the bills were in accordance with the fee schedule. I cannot stress enough that this is not a return to the Mary Immaculate v. Allstate glory days where “Defendant established Plaintiff’s prima facie case”. They won the business record dispute, but lost the need to only show a bill is overdue to shift the burden.
Related Articles
- Understanding the prima facie case requirements in no-fault insurance claims
- How the Fourth Department defines prima facie cases in no-fault litigation
- Avoiding common mistakes in establishing prima facie cases
- Business records requirements for prima facie showings in no-fault cases
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2014 post, New York’s no-fault regulations have undergone multiple amendments, including revisions to claim processing timeframes, billing form requirements, and prima facie case standards under Insurance Law Article 51. The fee schedules referenced have been updated several times, and procedural requirements for medical provider claims may have evolved. Practitioners should verify current provisions of the no-fault regulations and recent appellate decisions interpreting prima facie case requirements.
