Key Takeaway
Court decisions show consistent pattern: medical providers failing to submit proper affidavits of merit in medical necessity challenges will almost certainly lose at appellate level.
Medical necessity challenges represent one of the most common battlegrounds in New York no-fault insurance litigation. When insurance companies dispute whether medical services were truly necessary, they often file motions for summary judgment claiming the treatments weren’t medically justified. For healthcare providers seeking reimbursement, the response strategy can make or break their case.
The pattern emerging from appellate courts has become remarkably consistent across multiple judicial departments. Healthcare providers who fail to submit proper affidavits of merit when responding to medical necessity challenges find themselves facing almost certain defeat. This trend reflects the courts’ emphasis on substantive medical evidence rather than procedural arguments alone.
Understanding this judicial landscape is crucial for medical providers navigating the complex world of New York no-fault insurance law. The appellate courts have established clear expectations for how these disputes should be handled.
Jason Tenenbaum’s Analysis:
Elmont Open MRI & Diagnostic Radiology, P.C. v Clarendon Natl. Ins. Co., 2010 NY Slip Op 52061(U)(App. Term 2d Dept. 2010)
Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co., 2010 NY Slip Op 52062(U)(App. Term 2d Dept. 2010)
I know the above heading looks like some secret code that is necessary to enter a gambling hall. But it is important to understand that a plaintiff will almost always succumb to a defendant’s medical necessity motion, at both divisions of the Appellate Term, Second Department, when that plaintiff fails to answer a medical necessity motion with a proper affidavit of merit.
As such, I would look at each unrebutted motion for summary judgment based upon the lack of medical necessity of a particular service that you might have lost in District Nassau and file a Notice of Appeal. As long as your mailing is in place, I suspect the respective orders of the District Court will be reversed.
Key Takeaway
The appellate courts consistently reverse district court decisions favoring insurance companies when medical providers failed to submit proper affidavits of merit. This creates opportunities for medical necessity reversals on appeal, provided the procedural requirements for filing notices of appeal are met. Healthcare providers should carefully evaluate whether their lost cases qualify for appellate review.
Legal Update (February 2026): Since this 2010 analysis of appellate court trends regarding medical necessity challenges, New York no-fault regulations have undergone significant revisions, including updates to fee schedules under Insurance Regulation 68, amendments to claim filing procedures, and modifications to evidentiary standards for medical necessity disputes. Practitioners should verify current regulatory provisions and recent appellate decisions, as the judicial landscape for handling medical necessity challenges and affidavit requirements may have evolved considerably.
