Key Takeaway
Learn how summary judgment motions in no-fault insurance cases can backfire on carriers when discovery rules work against them in medical necessity disputes.
Elmont Open MRI & Diagnostic Radiology, PC v New York Cent. Mut. Fire Ins. Co., 2010 NY Slip Op 51588(U)(Dis. Ct. Nassau Co. 2010)
I would put this case in the “be careful what you ask for” category, because the insurance carrier got what it sought. To briefly explain, the insurance carrier filed a summary judgment motion based upon the services lacking medical reasonableness in accordance with a peer review. Plaintiff put in answering papers, bereft of an affidavit of merit.
District court ruled that the denial was timely mailed, but the submissions in support of the summary judgment motion were insufficient to prima facie establish a lack of medical necessity. I will get to this point later.
Somebody filed a notice of trial, a demand for a trial de novo was somewhere filed, and now this matter is on for trial. The insurance carrier seeks to have Plaintiff prove it mailed the claim forms, and to have Plaintiff lay a business record foundation for the admission of the bills into evidence.
At trial, District Court properly forced Plaintiff to lay a business record foundation for the admission of the claim forms into evidence, since Plaintiff never previously cross-moved for partial summary judgment and this issue was never adjudicated. The District Court, however, properly found that the insurance carrier’s summary judgment motion rendered the mailing issue moot. The fact is a summary judgment motion is the functional equivalent of a trial. If an affidavit states a bill was received and was denied, then it is impossible for an insurance carrier to escape that element of a plaintiff’s prima facie case during a later proceeding, i.e., the trial.
But this brings me to the title of my post. In a medical necessity case, an insurance carrier’s properly supported motion for summary judgment, includes the following: the denials, the affidavit of the claims representative indicating proof of receipt of the bill, the mailing of the denial, the IME or peer report and the underlying medical records. This documentary evidence affords the medical provider or injured person all the discovery they need to proceed to trial, provided the summary judgment motion is properly defeated. Furthermore, as seen above, this documentary evidence serves the exact function of verified interrogatories or an unanswered or admitted to Notice to Admit: admission of receipt of the bill and that the claim is overdue.
This now bring me to my last point. Were the MRI’s referred and prescribed by the chiropractor? If they were, then the case law seems to be that the medical reasonableness is determined through the shoes of the referring expert. I discussed this issue in previous posts. The point being that upholding the medical necessity based solely on Dr. Liguori’s medical records seems to be improper and an end around the chiropractor’s referral for the testing. Also, were the reviewed documents provided for in the summary judgment motion? If they were, then summary judgment should have been granted provided: the standard factual basis and medical rationale test was met and the said documents did not negate the peer review, i.e., Hillcrest MRI.
Perhaps this case should be appealed on the latter points?
Related Articles
- Understanding prima facie medical necessity requirements
- Peer review report challenges in Elmont Open MRI cases
- Why conclusory affidavits fail in medical necessity summary judgment motions
- First Department’s medical necessity ruling favoring insurance carriers
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2010 decision, New York’s no-fault regulations have undergone multiple amendments affecting summary judgment standards, medical necessity review procedures, and evidentiary requirements for business records in insurance disputes. Practitioners should verify current provisions of 11 NYCRR Part 65 and recent appellate decisions interpreting summary judgment motions in no-fault cases, as procedural and substantive standards may have evolved significantly.
