Key Takeaway
Three recent no-fault insurance cases demonstrate how plaintiffs consistently fail to provide adequate medical expert testimony to rebut insurance carriers' utilization reports.
Understanding Medical Utilization Reports in No-Fault Insurance Cases
In New York’s no-fault insurance system, insurance carriers frequently rely on medical utilization reports to deny claims for allegedly unnecessary treatments. These peer review reports evaluate whether medical services were medically necessary and appropriate. When carriers use these reports to deny coverage, healthcare providers must present compelling expert testimony to successfully challenge these denials.
The burden of proof in these cases often comes down to the quality and specificity of the medical expert’s affidavit. As seen in recent medical necessity reversals, courts require detailed, case-specific rebuttals that directly address the peer reviewer’s findings. Simply providing generic testimony or conclusory statements typically proves insufficient to overcome an insurance carrier’s medical utilization report.
Jason Tenenbaum’s Analysis:
Richmond Pain Mgt., P.C. v Clarendon Natl. Ins. Co., 2010 NY Slip Op 52015(U)(App. Term 2d Dept. 2010)
(my case) Radiology Today, P.C. v Mercury Ins. Co., 2010 NY Slip Op 52020(U)(App. Term 2d Dept. 2010). Dr. Shapiro’s affidavit was found not to sufficiently rebut the peer report. The Shapiro affidavit was somewhat detailed.
(my case) Delta Diagnostic Radiology, P.C. v Interboro Ins. Co., 2010 NY Slip Op 52022(U)(App. Term 2d Dept. 2010). This case also involves the failure to obtain a proper affidavit from a chiropractor; but the defect was overlooked due to the failure of the plaintiff to object to the same.
Key Takeaway
These cases highlight a persistent challenge in no-fault litigation: even detailed expert affidavits may fail to adequately rebut insurance carriers’ peer review reports. Healthcare providers must ensure their expert testimony specifically addresses each point raised in the utilization report and provides compelling medical reasoning to counter the denial. Procedural objections can also be waived if not timely raised during summary judgment motions.
Legal Update (February 2026): Since this 2010 post, New York’s no-fault insurance regulations have undergone significant revisions, including amendments to medical necessity standards, peer review procedures, and evidentiary requirements for challenging utilization reports. Additionally, court decisions over the past 15+ years may have refined the standards for sufficient medical expert testimony and rebuttal requirements. Practitioners should verify current regulatory provisions and recent case law when addressing medical utilization report challenges.
