In any action for first-party no-fault benefits, the provider derives its standing to recover benefits through an assignment of benefits form, whereby the patient (assignor) assigns to the medical provider (assignee) all rights, privileges and remedies to payment for health care services provided by the medical provider to which the patient is entitled under Article 51 of the Insurance Law.1 While there was a time when a plaintiff provider in a no-fault case was required to establish standing as part of its prima facie burden, there has been a clear and consistent shift in the case law away from this model, instead placing the burden on the defendant to raise a timely objection to the assignment.2 In this regard, the law is clear that a defendant insurer must timely object to the completeness of the no-fault claim forms submitted by a medical provider or seek verification of the assignment as required by 11 NYCRR 65.15 (d). Failure to do so will render any defenses based thereon, waived.3
Although the definition of what constitutes a prima facie case for first-party no-fault benefits in the state of New York has evolved over time and has often varied among appellate courts,4 it is relatively well settled that "[a] no-fault provider establishes its prima facie case ‘by proof of the submission to the defendant of a claim form, proof of the fact and the amount of the loss sustained, and proof either that the defendant had failed to pay or deny the claim within the requisite 30-day period, or that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law.’"5 Yet it seems that this issue continues to be litigated and subsequently appealed, with no end in sight.
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