Key Takeaway
Court reverses $4,300 judgment due to insufficient medical affidavit that failed to address insurer's peer review determination in no-fault case.
This case demonstrates a costly mistake that healthcare providers frequently make when defending medical necessity challenges in New York no-fault insurance disputes. The Appellate Term reversed a $4,300 judgment because the plaintiff’s medical affidavit was inadequate to create a genuine issue of fact regarding treatment necessity.
The decision highlights a critical procedural requirement: when an insurance company denies claims based on peer review findings, healthcare providers cannot simply restate their original medical opinions. Instead, they must specifically address and counter the insurer’s medical determination to survive summary judgment motions. This case also references the influential Pan Chiropractic decision, which established important precedents for medical necessity reversals in no-fault litigation.
Jason Tenenbaum’s Analysis:
Innovative Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co., 2010 NY Slip Op 50884(U)(App. Term 2d Dept. 2010)
“Appeal from an order…granting plaintiff’s cross motion for summary judgment, awarded plaintiff the principal sum of $4,250.90.”
“udgment is reversed without costs, the order entered March 18, 2009 is vacated, defendant’s motion for summary judgment dismissing the complaint is granted”
“The affidavit submitted by plaintiff in opposition to defendant’s motion was insufficient to raise a triable issue of fact, as it merely consisted of a conclusory statement by the affiant, the doctor who had provided the treatments, that he reaffirmed his opinion that the disputed services were medically necessary. The affiant did not refer to, or discuss, the determination of defendant’s chiropractors. Consequently, plaintiff failed to demonstrate the existence of an issue of fact with respect to medical necessity (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 NY Slip Op 51495 ), and defendant’s motion for summary judgment should have been granted.”
Key Takeaway
Healthcare providers must do more than simply reaffirm their medical opinions when opposing insurance company denials. Medical affidavits must specifically address and rebut the insurer’s peer review findings to create a triable issue of fact and avoid summary judgment dismissal.
Legal Update (February 2026): Since this 2010 decision, New York’s no-fault insurance regulations have undergone multiple revisions, including updates to peer review procedures, medical necessity standards, and affidavit requirements for healthcare providers challenging claim denials. Practitioners should verify current Insurance Regulation 68 provisions and recent Appellate Term decisions regarding the sufficiency of medical opposition evidence in summary judgment proceedings.
