The first of hopefully many

Understanding Medical Necessity in No-Fault Insurance: A Landmark Long Island Victory

For accident victims and healthcare providers on Long Island and throughout New York, medical necessity determinations represent one of the most contentious areas of no-fault insurance litigation. A recent appellate decision from Richmond County marks a significant shift in how courts approach these critical coverage disputes.

Bongiorno v State Farm: Breaking New Ground in Richmond County

****Bongiorno v State Farm Ins. Co.
****2009 NY Slip Op 50860(U)(App. Term 2d Dept. 2009)

This case is not remarkable in any way, except according to my calculations, it is the first time a judge in Civil Richmond was overturned on a denied lack of medical necessity summary judgment motion. Actually, I think it is the first time I have seen an appeal from Civil Richmond in a no-fault case in awhile.

Defense attorneys in some courts are told that medical necessity summary judgment motions are not welcome and will be summarily denied.

My hope is that some of the holdout judges in the Second Department, who refuse to grant summary judgment to a carrier’s lack of medical necessity motion-when same is not rebutted with any affirmative medical proof- will now follow suit.

Time will tell, as will more appeals should the rule of law not be followed.

Note – this reference does not apply to the First Department – as of now

Why This Decision Matters for Long Island Residents

The Bongiorno decision represents a crucial development for Nassau and Suffolk County residents dealing with no-fault insurance disputes. For too long, certain courts have been reluctant to grant summary judgment in favor of healthcare providers and patients when insurance carriers fail to provide credible medical evidence challenging the necessity of treatment.

This appellate reversal sends a clear message: when insurance companies deny coverage for medical necessity without providing competent medical evidence to support their position, courts should not automatically defer to the carrier’s determination.

The Problem with Automatic Denials

Before this decision, some courts had developed an unofficial policy of automatically denying medical necessity summary judgment motions, regardless of the strength of the evidence presented. This created an unfair burden on injured parties and healthcare providers who were forced into costly and time-consuming litigation even when the insurance carrier’s position was clearly without merit.

Medical Necessity Standards in New York No-Fault Cases

Under New York’s no-fault insurance law, carriers must pay for medical treatment that is “medically necessary.” However, disputes frequently arise over what constitutes medical necessity, and how much evidence each party must present to support their position.

Key Elements of Medical Necessity Claims

Successful medical necessity claims typically require:

• Proper medical documentation – Detailed records showing the relationship between injuries and treatment
• Physician support – Medical opinions supporting the necessity and appropriateness of care
• Treatment protocols – Evidence that care follows established medical guidelines
• Progress documentation – Records showing patient improvement or medical justification for continued care

Insurance Carrier Obligations

When challenging medical necessity, insurance carriers must provide more than conclusory denials. They need qualified medical opinions and evidence-based challenges to the treatment in question. The Bongiorno case reinforces that carriers cannot rely solely on blanket denials without supporting medical proof.

Strategic Implications for Healthcare Providers

This appellate victory provides important strategic advantages for healthcare providers treating accident victims:

Stronger Summary Judgment Position: Providers can now point to Bongiorno when seeking summary judgment against carriers who deny coverage without adequate medical support.

Reduced Litigation Costs: Courts should be more willing to resolve clear-cut cases without lengthy trials, saving time and resources for both parties.

Precedential Value: While this decision comes from Richmond County, it carries persuasive authority throughout the Second Department, which includes Nassau and Suffolk Counties.

Impact on Different Appellate Departments

The legal landscape varies significantly between New York’s appellate departments. While the Second Department (covering Long Island) shows increasing willingness to scrutinize insurance carrier denials, the First Department maintains different standards and approaches to these cases.

For Long Island residents, this geographic difference can be crucial in case strategy and venue selection when multiple forum options exist.

Frequently Asked Questions

What does “medical necessity” mean in no-fault insurance cases?

Medical necessity refers to treatment that is appropriate, reasonable, and required for diagnosis or treatment of injuries sustained in a motor vehicle accident. Treatment must be consistent with generally accepted medical standards and specifically related to accident-related injuries.

How does the Bongiorno decision affect my pending no-fault case?

If your insurance carrier has denied coverage for medical necessity without providing qualified medical evidence supporting their denial, the Bongiorno decision strengthens your position for seeking summary judgment or challenging the carrier’s determination.

What evidence do I need to prove medical necessity?

Strong medical necessity claims require detailed medical records, physician reports explaining the relationship between accident injuries and treatment, documentation of treatment protocols, and evidence of patient progress or medical justification for continued care.

Can insurance carriers simply deny claims without medical evidence?

No. The Bongiorno decision reinforces that insurance carriers must provide competent medical evidence to support their medical necessity challenges. Conclusory denials without supporting medical proof are insufficient.

How long do medical necessity disputes typically take to resolve?

Timeline varies based on case complexity, court schedules, and whether summary judgment is appropriate. With stronger precedent like Bongiorno, clear-cut cases may resolve more quickly through motion practice rather than lengthy trials.

Protecting Your Rights in Medical Necessity Disputes

The Bongiorno decision represents an important victory for accident victims and healthcare providers, but insurance carriers continue to challenge legitimate claims through various tactics. Having experienced legal representation ensures your rights are protected and helps maximize your recovery.

At the Law Office of Jason Tenenbaum, we understand the evolving landscape of no-fault insurance law and how appellate decisions like Bongiorno can benefit our clients. We work aggressively to hold insurance carriers accountable when they deny legitimate medical necessity claims without proper evidence.

Whether you’re a healthcare provider seeking reimbursement or an accident victim whose treatment has been denied, we have the experience and track record to fight for your rights. Our knowledge of local court practices in Nassau and Suffolk Counties, combined with our understanding of appellate precedents, helps ensure the best possible outcome for your case.

Don’t let insurance carriers deny your legitimate medical necessity claims. Contact our office today at 516-750-0595 for a consultation. We’ll review your case, explain your rights under decisions like Bongiorno, and fight to ensure you receive the coverage and compensation you deserve.

Related Articles

• Understanding peer review reports in medical necessity determinations
• Why conclusory affidavits fail in opposing medical necessity summary judgment motions
• How objective standards apply in medical rational cases
• When civil court reasoning goes wrong in no-fault insurance cases
• New York No-Fault Insurance Law

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Legal Update (February 2026): Since this 2009 post, New York’s no-fault insurance regulations have undergone significant revisions, including updates to medical necessity standards, fee schedules, and procedural requirements for summary judgment motions. Practitioners should verify current provisions under the most recent Insurance Law amendments and regulatory updates, as judicial approaches to medical necessity determinations may have evolved considerably over the intervening years.