Key Takeaway
Learn effective strategies for defeating medical necessity motions in New York no-fault insurance cases. Expert legal insights on peer review challenges.
Understanding Medical Necessity Motions in New York No-Fault Law
When you’re injured in an automobile accident on Long Island or in the New York City area, your no-fault insurance coverage is supposed to provide timely payment for medically necessary treatments. However, insurance companies frequently challenge medical bills through summary judgment motions, claiming services lack medical necessity based on peer reviews. Understanding how to effectively defend against these motions is crucial for both healthcare providers and injured patients.
The Common Problem with Peer Review-Based Motions
I encounter on many levels summary judgment motions predicated upon the defense that a service lacks medical necessity in accordance with a peer review which finds that a given service is medically unreasonable. Invariably, the motion only annexed the peer review.
The opponent to the motion now has to scramble to find the documents the peer reviewer examined, and then the opponent needs to retain an expert to review these records in order to conclude that the services were medically necessary.
I think we missed a step here. Why was the movant able to get away with attaching a FILE based review without annexing the file? Are we to throw caution to the wind and blindly trust the peer doctor’s interpretation of the plaintiff’s records? Indeed, the way plaintiffs win trials is through poking holes in the peer doctor’s medical rationale viz a vi the plaintiff’s medical records. Conversely, a defendant faced with a treating doctor will do the same thing to beat him or her.
Perhaps the better question is why, mister plaintiff did you not object to the defendant’s putting the cart before the horse through his making a summary judgment motion without any documentaty evidence to support it?
Maybe the question that really needs to be answered is why we allow ourselves to accept shoddy practices and mediocrity under the guise of “volume”?
The Legal Foundation: Cariddi v. Hassan
The Appellate Division, in 2006 believed that what has now been the norm in no-fault medical necessity motion practice was unsatisfactory in an analagous scenario and found that the movant who pulled the above stunt was unable to prima facie demonstrate his defense to the action.
In Cariddi v. Hassan 45 AD3d 516 (2d Dept. 2006), the Appellate Division held the following:
While Dr. Katz provided objective medical evidence in support of his diagnoses with respect to the plaintiff’s complaints regarding her ankle and lumbosacral spine, his only basis for concluding that the plaintiff’s complaints regarding her hip were “unrelated” to the subject accident was that “doctors’ notes reviewed do not indicate any problem to the left hip following this incident of 09/17/04 n MRI of the left hip and pelvis was not performed until 01/03/06 which is more than one year after the accident.” However, Dr. Katz did not attach any of the prior medical records to his report, and the defendants otherwise failed to submit any such records in support of their motion, as they were certainly entitled to do (see Kearse v. New York City Tr. Auth., 16 A.D.3d 45, 47 n. 1, 789 N.Y.S.2d 281; Pagano v. Kingsbury, 182 A.D.2d 268, 271, 587 N.Y.S.2d 692). Therefore, Dr. Katz’s report, standing alone, failed to establish, prima facie, that the plaintiff’s alleged hip injury was unrelated to the subject accident
Practical Strategy for Long Island and NYC Cases
For personal injury attorneys practicing in Nassau, Suffolk, Queens, Kings, Bronx, and Manhattan counties, this decision provides a clear roadmap for challenging inadequately supported medical necessity motions. Here are key strategic considerations:
1. Immediate Objection Requirements
Of course, one caveat needs to be stressed. The failure to object to a moving party’s reliance on materials not before the court is waived if not properly objected to. Unobjected to hearsay is competent evidence. Use it or lose it. Oh, and this does not apply to IME based motions.
2. Documentary Evidence Standards
When insurance companies submit peer review reports without attaching the underlying medical records that were reviewed, they fail to meet their prima facie burden. This creates an opportunity for plaintiffs to move for summary judgment rather than simply defending against the insurer’s motion.
3. Local Court Considerations
Nassau County Supreme Court, Suffolk County Supreme Court, and the various New York City venues each have their own approaches to summary judgment practice. Understanding local rules and judicial preferences can be crucial when raising these objections.
Why This Matters for Long Island Accident Victims
No-fault insurance disputes affect thousands of Long Island residents annually. Whether you were injured in a Nassau County car accident on the Long Island Expressway, a Suffolk County intersection collision, or a New York City borough incident, understanding your rights regarding medical necessity determinations is essential.
Insurance companies often use the high volume of claims as justification for shortcuts in their motion practice. However, injured parties deserve thorough, well-supported evaluations of their medical treatments, not superficial peer reviews that lack documentary foundation.
Frequently Asked Questions
Q: What constitutes a proper peer review for summary judgment purposes?
A: A proper peer review motion should include not only the expert’s opinion but also copies of all medical records, reports, and documentation that the peer reviewer relied upon in forming their opinion.
Q: Can I challenge a peer review if I disagree with the findings?
A: Yes, but you must act quickly. If the insurance company fails to provide the underlying documentation with their motion, you should object immediately. Failure to object waives this defense.
Q: How does this affect my no-fault benefits?
A: If an insurance company wins a motion based on inadequate peer review documentation, you could be denied coverage for necessary medical treatment. Proper legal representation ensures these motions meet appropriate evidentiary standards.
Q: What’s the difference between peer review motions and IME-based motions?
A: The documentary requirements discussed in Cariddi v. Hassan do not apply to Independent Medical Examination (IME) based motions, which have different procedural requirements under New York law.
Q: Should I hire an attorney for no-fault disputes?
A: Given the complex procedural requirements and the risk of waiving important objections, having experienced legal representation is strongly recommended for significant no-fault disputes.
Contact a Long Island No-Fault Attorney
If you’re facing challenges with your no-fault insurance coverage, or if you’re a healthcare provider dealing with inadequately supported medical necessity motions, don’t accept shoddy motion practice. The law requires insurance companies to properly support their positions with actual evidence, not just conclusory expert reports.
For experienced representation in Nassau County, Suffolk County, and throughout the New York metropolitan area, call 516-750-0595 to discuss your case. Our office understands both the legal requirements for proper motion practice and the practical realities of no-fault insurance disputes in the Long Island and NYC area.
Related Articles
- Why Conclusory Affidavits Fail: Building Strong Opposition to Medical Necessity Summary Judgment Motions
- Medical Necessity in No-Fault Insurance: Understanding the First Department’s Victory for Insurance Carriers
- A prima facie case of medical necessity?
- May an insurance carrier’s expert offer an opinion beyond the confines of his peer or IME report?
- New York No-Fault Insurance Law
Legal Update (February 2026): Since 2009, New York’s no-fault regulations have undergone several amendments affecting medical necessity determinations and peer review procedures, including changes to required documentation standards and evidentiary requirements for summary judgment motions. Practitioners should verify current provisions in 11 NYCRR Part 65 and recent case law developments regarding the sufficiency of peer review evidence in contested medical necessity determinations.
