Key Takeaway
Court affirms that third-party biller testimony alone can establish prima facie case in no-fault insurance disputes, following Viviane Etienne precedent.
In New York’s no-fault insurance system, healthcare providers must establish a “prima facie case” to recover payment for services rendered to injured patients. This legal standard requires presenting sufficient evidence to prove each element of a claim, after which the burden shifts to the insurance company to present a valid defense. The question of what constitutes adequate proof has been the subject of numerous court decisions, particularly regarding who can testify on behalf of medical practices.
The threshold for establishing a prima facie case is intentionally low - courts recognize that healthcare providers shouldn’t face unnecessary barriers when seeking legitimate reimbursement. However, insurance companies often challenge the sufficiency of evidence presented, leading to ongoing litigation about witness requirements and documentation standards.
This case demonstrates how the Appellate Term has consistently applied precedent from Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., which established that third-party billing personnel can provide adequate foundation testimony. This ruling has been particularly significant for medical practices that rely on external billing companies, though its application has varied across different judicial departments.
Jason Tenenbaum’s Analysis:
Peace of Mind, Social Work, P.C. v Travelers Aetna Prop. Cas. Corp., 2014 NY Slip Op 50475(U)(App. Term 2d Dept. 2013)
“The sole witness was plaintiff’s third-party biller.”
“Pursuant to the holding in Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. ( ___ AD3d ___, 2013 NY Slip Op 08430 ), the testimony of plaintiff’s witness was sufficient to establish plaintiff’s prima facie case. As defendant failed to proffer a defense, the judgment is affirmed”
Key Takeaway
The Appellate Term reaffirmed that testimony from a third-party billing representative alone can satisfy the prima facie standard in no-fault cases. When insurance companies fail to present adequate defenses, courts will rule in favor of healthcare providers who meet this minimal evidentiary threshold. This decision reinforces the Etienne precedent, though practitioners should note that different departments may apply this standard differently.
