New York Law Review

Tag: preclusion

  • Viviane Etienne Medical Care, P.C. v. Country-Wide Ins. Co., 25 N.Y.3d 133 (2015): Establishing Prima Facie Entitlement in No-Fault Insurance Claims

    25 N.Y.3d 133 (2015)

    In a no-fault insurance case, a medical provider establishes a prima facie case for summary judgment by submitting evidence of mailing and receipt of statutory billing forms by the insurer, which then failed to pay or deny the claim within the statutory timeframe.

    Summary

    The New York Court of Appeals addressed the standard of proof required for a medical provider to obtain summary judgment in a no-fault insurance action. The Court held that a plaintiff demonstrates a prima facie entitlement to summary judgment by providing evidence that the statutory billing forms were mailed to and received by the insurer, and the insurer did not pay or deny the claims within the statutory 30-day period. The Court clarified that while the insurer might be precluded from raising defenses due to a failure to timely deny the claim, the medical provider still has the initial burden of demonstrating entitlement to reimbursement by submitting admissible proof. This ruling emphasizes the streamlined nature of no-fault insurance and reinforces the prompt payment requirements of the No-Fault Law.

    Facts

    Alem Cardenas was injured in a car accident and received medical treatment from Viviane Etienne Medical Care, P.C. (plaintiff). Cardenas assigned his right to no-fault benefits to the plaintiff. The plaintiff submitted eight verification of treatment forms to Country-Wide Insurance Company (defendant), seeking reimbursement for services provided. The defendant did not timely deny most of the claims, but denied one. The plaintiff sued to recover the unpaid benefits, along with interest and attorney’s fees. The plaintiff moved for summary judgment, supporting its motion with the forms, mailing ledgers, and an affidavit from a third-party billing company. The defendant opposed the motion, arguing that the plaintiff failed to meet its burden because the evidence was hearsay. The lower courts disagreed on whether the plaintiff had established a prima facie case. The Appellate Division granted summary judgment for the plaintiff, leading to this appeal.

    Procedural History

    The Civil Court denied the plaintiff’s motion for summary judgment. The Appellate Term affirmed the Civil Court’s decision. The Appellate Division reversed and granted the plaintiff’s motion for summary judgment. The Appellate Division certified a question for the Court of Appeals: whether its determination was properly made.

    Issue(s)

    1. Whether a medical provider in a no-fault insurance action establishes a prima facie case for summary judgment by submitting evidence of mailing and receipt of statutory billing forms by the insurer and the insurer’s failure to deny or pay within the statutory timeframe?

    Holding

    1. Yes, because a medical provider meets its burden when it demonstrates the mailing of the proof of claim forms and their receipt by the insurer, and the insurer did not take the required action within the statutory timeframe.

    Court’s Reasoning

    The Court of Appeals emphasized that the No-Fault Law aims to ensure prompt compensation without regard to fault. The Court reiterated that an insurer’s failure to pay or deny a claim within 30 days of receiving proof of claim results in preclusion from asserting most defenses. To obtain summary judgment, the medical provider needs to submit proof in admissible form. This could include the verification of treatment form and/or an affidavit from a person with knowledge of how the claim was sent to the insurer, or who has relied upon the forms in the performance of their business. The Court found that the plaintiff’s submission, including the affidavit of the billing company’s president, sufficiently demonstrated the mailing and receipt of the claim forms. The business records exception to the hearsay rule was satisfied, allowing the forms and affidavit to be considered as admissible evidence. The court cited precedent that, "in this context, the plaintiff makes a prima facie showing of entitlement to judgment as a matter of law by submitting evidence, in admissible form, that the prescribed statutory billing forms were mailed to and received by the defendant insurer, which failed to either pay or deny the claim within the prescribed 30-day period."

    Practical Implications

    This decision provides clarity on the evidentiary requirements for medical providers seeking summary judgment in no-fault cases. It clarifies that providers must submit admissible proof of mailing and receipt of billing forms, and that the insurer must then respond to claims within the statutory 30-day period to avoid preclusion and potentially be subject to interest and attorney’s fees. This ruling influences how attorneys prepare and present evidence in no-fault insurance litigation. It supports a streamlined process for resolving payment disputes and highlights the importance of timely claim handling by insurers. Moreover, the decision reinforces the consequences for insurers that fail to adhere to the strict deadlines of the No-Fault Law, which are designed to promote swift payment to those who are entitled to it. Later cases will need to consider the specific facts and how the evidence presented by the plaintiff satisfies these requirements.

  • People v. Bernier, 73 N.Y.2d 1006 (1989): Consequences of Failing to Provide Timely Notice of Identification Testimony

    People v. Bernier, 73 N.Y.2d 1006 (1989)

    When the prosecution fails to provide timely notice of intent to use identification testimony, as required by CPL 710.30, preclusion is mandatory unless a valid excuse exists for the lack of notice, and a defendant does not waive the right to preclusion by subsequently participating in a suppression hearing after the initial motion to preclude was denied.

    Summary

    Defendant was convicted of robbery and weapons possession. During jury selection, the defense learned of an unnoticed identifying witness. The defense moved to preclude the testimony due to lack of notice. The court denied the motion, but ordered a Wade hearing after the prosecutor admitted an out-of-court identification occurred. After the initial suppression, the court reopened the hearing to establish an independent source for the in-court identification. The Appellate Division reversed, suppressing the in-court identification. The Court of Appeals affirmed, holding that the initial failure to provide statutory notice mandated preclusion, and the defendant did not waive this right by participating in the Wade hearing after the initial motion to preclude was denied.

    Facts

    The defendant was charged with robbery and weapons possession related to three separate incidents at the same gas station. During jury selection, the defense became aware of a witness, Gedeon, who would be the prosecution’s primary identifying witness, but for whom no prior notice had been given as required by CPL 710.30(1). The prosecutor acknowledged that an out-of-court identification had been made by Gedeon.

    Procedural History

    The trial court initially denied the defendant’s motion to preclude Gedeon’s testimony but ordered a Wade hearing. The Wade hearing resulted in suppression of the out-of-court identification. The prosecution then successfully moved to reopen the Wade hearing to establish an independent source for an in-court identification. The trial court then allowed Gedeon to make an in-court identification. The Appellate Division reversed the conviction and suppressed the in-court identification. The People appealed to the New York Court of Appeals.

    Issue(s)

    1. Whether the trial court erred in denying the defendant’s initial motion to preclude identification testimony when the prosecution failed to provide timely notice as required by CPL 710.30.

    2. Whether the defendant waived the protection of CPL 710.30 by participating in a Wade hearing after the initial motion to preclude was denied.

    Holding

    1. Yes, because the People failed to present any valid excuse for not giving the required notice under CPL 710.30, requiring preclusion of the identification testimony.

    2. No, because the waiver exception of CPL 710.30(3) does not apply when the defendant initially moved to preclude and lost, and the defendant made no suppression motion qualifying under CPL 710.30(3).

    Court’s Reasoning

    The Court of Appeals affirmed the Appellate Division’s decision, emphasizing the mandatory nature of CPL 710.30. The court stated, “Inasmuch as the People failed to present or establish any excuse for not giving the required notice, the court should have granted the preclusion motion and suppressed the identification testimony.” The court explicitly referenced People v. O’Doherty, 70 NY2d 479, which firmly established the consequences for failing to adhere to the statutory notice requirements. The Court also rejected the People’s argument that the defendant waived his right to preclusion by participating in the Wade hearing after his initial motion to preclude had been denied. Quoting, “The waiver exception cannot become operative in a case such as this when the defendant clearly moved initially to preclude and lost. In any event, he made no suppression motion qualifying under CPL 710.30 (3) (see, People v Amparo, 73 NY2d 728, 729; People v McMullin, 70 NY2d 855).” The court’s decision underscores the importance of strict compliance with CPL 710.30 and clarifies that a defendant’s participation in subsequent suppression proceedings, after an initial preclusion motion is wrongly denied, does not constitute a waiver of their right to challenge the identification testimony. This prevents the prosecution from benefitting from its initial failure to provide timely notice. The case serves as a reminder that the prosecution bears the burden of demonstrating a valid excuse for failing to provide timely notice of identification testimony, and absent such an excuse, preclusion is the required remedy.