Key Takeaway
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Why Poorly Drafted Medical Affidavits Fail Against Insurance Medical Necessity Motions
In the complex world of New York no-fault insurance litigation, particularly across Long Island and the greater New York City metropolitan area, healthcare providers face increasingly sophisticated challenges from insurance carriers. One of the most critical battlegrounds involves medical necessity summary judgment motions, where the quality of your medical opposition can make or break your case.
At the Law Office of Jason Tenenbaum, we’ve represented countless healthcare providers throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island in these high-stakes battles. Our experience has shown that the difference between success and failure often comes down to the quality and precision of the medical affidavits submitted in opposition to insurance carriers’ motions.
The Case That Illustrates the Problem
My medical necessity summary judgment crusade continues.
Gz Med. & Diagnostic, P.C. v Mercury Ins. Co., 2010 NY Slip Op 50491(U)(App. Term 2d Dept. 2010)
We have seen this before: “In opposition to the motion, plaintiff failed to raise a triable issue of fact. Contrary to the finding of the Civil Court, the affirmation of plaintiff’s doctor did not meaningfully refer to, let alone rebut, the conclusions set forth in the peer review report (id.; see also Innovative Chiropractic, P.C. v Mercury Ins. Co., 25 Misc 3d 137, 2009 NY Slip Op 52321 ).”
Besides this case and those like it, I would say that the plaintiffs are getting better at defeating these types of motions. This only makes sense. I mean, in a similar vain, would it make sense after 3-4 years of losing cases based upon the “mailing” issue, for carriers not to figure out how to craft procedures and draft affidavits that would raise the inference that an item was mailed?
As I have also said before, however, the Appellate Term recently gave two free passes, on medical necessity summary judgment motion, to firms that should be eternally grateful that the contents of their papers were not exposed.
Understanding Medical Necessity Summary Judgment Motions in New York
For healthcare providers serving patients across Long Island and New York City, understanding the mechanics of medical necessity challenges is crucial for practice sustainability. Insurance carriers have become increasingly aggressive in their use of peer review reports to challenge the medical necessity of treatments, particularly in high-volume specialties like chiropractic care, acupuncture, and diagnostic imaging.
The Evolution of Carrier Strategy
Over the past decade, we’ve witnessed a significant evolution in how insurance carriers approach medical necessity denials. What started as relatively straightforward challenges has evolved into sophisticated legal strategies backed by carefully crafted peer review reports and meticulously planned summary judgment motions.
Insurance carriers have learned from their early mistakes. Just as they adapted their procedures to address “mailing” issues in claims processing, they’ve now developed more sophisticated approaches to medical necessity challenges that make them increasingly difficult to defeat without equally sophisticated opposition.
The Critical Importance of Quality Medical Opposition
For medical practices throughout Nassau and Suffolk Counties, as well as the five boroughs, the stakes couldn’t be higher. A successful medical necessity summary judgment motion by an insurance carrier can result in significant financial losses and, potentially, a precedent that affects future cases.
What Makes an Affidavit “Poorly Drafted”?
Based on our extensive experience defending healthcare providers against these motions, we’ve identified several common characteristics of ineffective medical affidavits:
- Generic responses that fail to address specific peer review findings
- Conclusory statements without supporting medical reasoning
- Failure to engage with the carrier’s medical expert’s specific conclusions
- Insufficient medical foundation for the treating physician’s opinions
- Lack of specificity regarding the patient’s particular condition and treatment needs
- Inadequate explanation of how the treatment relates to the underlying accident
The Standard for Effective Medical Opposition
To successfully oppose a medical necessity summary judgment motion, healthcare providers must demonstrate that their treatment was both reasonable and necessary. This requires more than simply stating that the treatment was appropriate—it requires a detailed, medically sound explanation that directly addresses and refutes the insurance carrier’s peer review findings.
Strategic Considerations for Long Island and NYC Providers
The competitive medical landscape in New York, particularly in areas like Long Island where no-fault claims are prevalent, means that providers must be prepared for increasingly sophisticated challenges to their billing practices.
The Importance of Documentation
Successful defense against medical necessity challenges begins long before any motion is filed. It starts with comprehensive documentation of patient care that clearly establishes:
- The relationship between the patient’s injuries and the motor vehicle accident
- The medical necessity for each type of treatment provided
- The patient’s response to treatment and ongoing needs
- The basis for treatment frequency and duration
Building Strong Opposition Papers
When faced with a medical necessity summary judgment motion, providers need medical affidavits that:
- Specifically address each conclusion in the peer review report
- Provide medical reasoning for why the peer reviewer’s conclusions are incorrect
- Reference specific patient records and examination findings
- Explain the medical basis for treatment decisions
- Demonstrate the provider’s qualifications to render the opinions stated
Frequently Asked Questions About Medical Necessity Defense
Q: How can I tell if my medical affidavit is strong enough to defeat a summary judgment motion?
A: An effective affidavit must do more than simply contradict the peer reviewer’s conclusions. It must provide specific medical reasoning, reference particular patient findings, and demonstrate why your treatment approach was medically necessary and appropriate.
Q: What happens if I lose a medical necessity summary judgment motion?
A: A successful motion by the insurance carrier typically results in judgment in their favor, meaning you won’t recover payment for the disputed services. Additionally, it may establish precedent for future cases with similar fact patterns.
Q: How long do I have to respond to a medical necessity summary judgment motion?
A: Response deadlines vary depending on the court and method of service, but generally range from 8 to 35 days. It’s crucial to begin preparing your opposition immediately upon receiving the motion.
Q: Can I use the same medical expert for multiple similar cases?
A: While you can use the same expert, each affidavit must be specifically tailored to the individual case. Generic or template responses are more likely to be ineffective.
Q: Should I settle rather than fight a medical necessity motion?
A: The decision depends on various factors, including the strength of your medical evidence, the amount in dispute, and the potential precedential value of the case. This requires careful strategic analysis.
The Broader Implications for Healthcare Providers
The increasing sophistication of insurance carrier challenges has broader implications for healthcare providers across New York. Practices that fail to adapt their documentation and litigation strategies risk falling behind in an increasingly competitive environment.
Quality Over Quantity
While volume practices may seem economically attractive, they often result in inadequate documentation that becomes vulnerable to medical necessity challenges. Providers must balance efficiency with the thorough documentation necessary to defend their treatment decisions.
The Importance of Continuing Education
As peer review standards evolve and insurance carrier strategies become more sophisticated, healthcare providers must stay current with developments in their fields. This includes understanding not just clinical developments, but also the legal and regulatory environment in which they practice.
Why Experience Matters in Medical Necessity Defense
The complexity of medical necessity litigation requires legal counsel with deep understanding of both the medical and legal issues involved. Our team has handled hundreds of these cases and understands what separates successful opposition papers from those that fail to create triable issues of fact.
We work closely with qualified medical experts who understand the standards required for effective affidavits. More importantly, we understand how to present medical evidence in a way that courts find compelling and legally sufficient.
Protecting Your Practice’s Future
For healthcare providers throughout Long Island and New York City, the stakes in medical necessity litigation continue to rise. Insurance carriers are becoming more sophisticated in their challenges, and providers must be equally sophisticated in their defense.
This means not just having good medical care, but also ensuring that care is properly documented and, when challenged, effectively defended. The cost of inadequate legal representation in these matters can far exceed the immediate financial impact of any single case.
Contact Our Medical Necessity Defense Team
If your healthcare practice is facing medical necessity challenges or other no-fault insurance disputes, don’t leave your practice’s financial future to chance. The quality of your legal representation can make the difference between success and failure in these critical cases.
Contact the Law Office of Jason Tenenbaum today at (516) 750-0595 to discuss your medical necessity defense needs. We serve healthcare providers throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island.
Don’t let poorly drafted opposition papers jeopardize your practice’s financial stability. Call us today and ensure your medical necessity defenses meet the increasingly demanding standards of New York’s courts.
Related Articles
- How conclusory affidavits fail against medical necessity motions
- Understanding the convergence of medical malpractice and no-fault litigation principles
- Effective strategies for peer review rebuttals in no-fault cases
- Why insufficient affidavits lose against lack of medical necessity motions
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2010 post, New York’s no-fault regulations have undergone several amendments affecting medical necessity standards and peer review procedures, including updates to fee schedules and procedural requirements for medical affidavits. Additionally, Appellate Term decisions have continued to evolve regarding the sufficiency standards for medical opposition papers. Practitioners should verify current regulatory provisions and recent case law when drafting medical necessity opposition papers.
