Uncertified Treating Physician Records Can Defeat a Serious Injury Claim: Uribe v Jimenez

Key Takeaways

• The Second Department held a threshold-motion defendant may rely on the plaintiff’s own treating physician records even though they are uncertified.
• The operative phrase is “plaintiff’s treating physicians” — the relaxed admissibility rule turns on whose records they are, not who offers them.
• In Uribe, Elmhurst Hospital records showing a chest X-ray with no rib fractures carried the defendant’s prima facie burden.
• Plaintiffs cannot manufacture an admissibility objection to their own treatment records on a 5102(d) motion.

In personal injury litigation, defendants often face the challenge of proving that a plaintiff has not sustained a “serious injury” as defined under New York’s no-fault insurance law. One common strategy involves presenting medical evidence that contradicts the plaintiff’s claims. However, questions frequently arise about what types of medical records can be relied upon and whether they need special certification or authentication.

The distinction between treating physician records and other medical documentation becomes particularly important in cases involving New York No-Fault Insurance Law, where establishing the threshold of serious injury is crucial. Unlike situations where defendants might struggle with procedural requirements, such as proper IME notification procedures, the use of treating physician records offers a more straightforward evidentiary path.

The Decision

Jason Tenenbaum’s Analysis:

Uribe v Jimenez, 2015 NY Slip Op 08726 (2d Dept. 2015)

“In support of his motion, the defendant submitted the plaintiff’s medical records from Elmhurst Hospital, which indicated that a chest X ray did not reveal any rib fractures (see Estaba v Quow, 74 AD3d 734, 734-735). While these medical records were not certified, the defendant could rely on them in order to demonstrate a lack of serious injury, as they were the records of the plaintiff’s treating physicians”

Nothing new to report but the Court held as a matter of law that defendants could rely on the records of the plaintiff’s treating physicians. It is the line plaintiff’s treating physicians that is important to note.

The Legal Framework: Threshold Motions and Admissibility

New York’s no-fault scheme bars a suit for non-economic loss arising from a motor vehicle accident unless the plaintiff sustained a “serious injury” under Insurance Law § 5102(d) — a list that includes fracture, permanent consequential limitation, significant limitation of use, and other defined categories. On a summary judgment motion under CPLR 3212, the defendant bears the initial burden of making a prima facie showing that the plaintiff did not sustain a qualifying injury; only then must the plaintiff come forward with admissible medical evidence raising a triable issue.

The general rule on summary judgment is that the movant’s proof must be in admissible form, and medical records ordinarily come in as business records, typically through certification under CPLR 4518(c). The threshold context, however, has developed a practical carve-out: a defendant may rely on the plaintiff’s own treatment records, certified or not, to show the absence of a serious injury. The logic is fairness-based. The records were generated by the plaintiff’s own providers in the course of the plaintiff’s own care; the plaintiff is poorly positioned to disclaim documents reflecting his or her own treatment history. Uribe applies that rule cleanly: uncertified Elmhurst Hospital records showing a chest X-ray negative for rib fractures sufficed to carry the defendant’s burden on the fracture category.

Note the limit built into the holding. The relaxed standard attaches to the records of the plaintiff’s treating physicians. A defendant cannot extend the same latitude to third-party records with no connection to the plaintiff’s treatment, and a plaintiff opposing the motion still must answer with proof in admissible form — typically a sworn report from a physician addressing causation and quantified limitations.

Why This Matters for Threshold Practice

For defense counsel and carriers, Uribe removes a procedural trap. Hospital records subpoenaed or exchanged in discovery frequently arrive without certification, and chasing certifications for a motion deadline is a needless burden when the records belong to the plaintiff’s own providers. The decision lets the defense build a threshold motion on emergency room records, imaging reports, and treatment notes as they sit in the file — material that is often the most damaging proof available, because a plaintiff’s own records can defeat the claim more credibly than any retained expert.

For plaintiffs’ counsel, the lesson runs the other way. The contents of the treating file are effectively party admissions for threshold purposes. A claimed fracture that the contemporaneous X-ray report negates, or claimed limitations absent from the contemporaneous treatment records, will surface in the defendant’s moving papers without any admissibility screen to hide behind. Pleading injuries the treating records do not support invites exactly the motion that succeeded in Uribe.

Practice Pointers

• Defendants: mine the plaintiff’s certified and uncertified treating records early. Negative imaging reports and silent emergency room charts are prima facie gold on fracture and limitation categories.
• Defendants: pair the records with an examining physician’s affirmation where the categories require quantified range-of-motion findings; the records alone may not address every pleaded category.
• Plaintiffs: audit the bill of particulars against the treating chart before opposing. Withdraw unsupported categories rather than letting the court reject them wholesale.
• Plaintiffs: remember the asymmetry — your opposition still requires admissible proof, ordinarily affirmed or sworn medical reports addressing causation and contemporaneous findings.

Frequently Asked Questions

Can a defendant use uncertified medical records in a New York serious injury motion?

Yes, if they are the plaintiff’s own treating providers’ records. In Uribe v Jimenez, the Second Department held the defendant could rely on uncertified Elmhurst Hospital records to demonstrate a lack of serious injury because they were the records of the plaintiff’s treating physicians.

Who has the burden of proof on a 5102(d) threshold motion?

The defendant moving for summary judgment bears the initial burden of establishing, prima facie, that the plaintiff did not sustain a serious injury within Insurance Law § 5102(d). If that showing is made, the burden shifts to the plaintiff to raise a triable issue of fact with medical evidence in admissible form.

Why do treating physician records carry special weight?

They are generated in the course of the plaintiff’s own care, contemporaneously with treatment, by providers the plaintiff selected. Courts treat them as inherently reliable as against the plaintiff, which is why a plaintiff cannot block their use on certification grounds.

Related Resources

• Pre-existing injuries in New York personal injury cases — cluster hub
• A Plaintiff’s own hospital records defeated his own threshold summary judgment motion
• Contemporaneous medical records sufficient
• A Prima facie showing of lack of serious injury does not require a review of plaintiff’s records
• Browse the firm’s Legal Encyclopedia for foundational NY evidence and no-fault doctrine
• Personal Injury | Long Island Car Accident Lawyer