Key Takeaway
A dissenting judge criticizes vague peer review reports in no-fault insurance cases, highlighting the importance of detailed medical necessity determinations.
No-fault insurance cases often turn on peer review reports that assess whether medical treatments were necessary. These reports serve as critical evidence when insurance companies deny claims, but the quality and detail of these evaluations can vary significantly. In MSSA Corp. v Redland Insurance Company, a dissenting opinion shed light on what constitutes an adequate peer review analysis.
The case illustrates ongoing tensions in New York No-Fault Insurance Law regarding the standards for peer review reports. While some courts accept minimal explanations from reviewing physicians, others demand more comprehensive analysis to justify treatment denials.
Jason Tenenbaum’s Analysis:
MSSA Corp. v Redland Ins. Co., 2011 NY Slip Op 51606(U)(App. Term 2d Dept. 2011).
A case more remarkable for Justice Steinhardt’s dissent:
“In the instant matter, the peer review report of Dr. Ross did not “shed any light” on the assignor’s condition, nor did it state, in any sufficiently detailed manner, the reason the medical equipment at issue was not needed. The reader of the report is at a total loss to determine what actually happened to the assignor and what parts of her anatomy are amiss and in what way. “Bilateral shoulder and left elbow” injuries may range from a complicated fracture to a minor contusion. Without more, the report is conclusory and vague, and insufficient to shift the burden to plaintiff. I therefore vote to affirm the order denying defendant’s motion for summary judgment.”
The question here involves what needs to be in a peer review to demonstrate prima facie a lack of medical necessity for rendered services. It is interesting that certain judges are reading these peer reports in a more than perfunctory manner.
Key Takeaway
Justice Steinhardt’s dissent emphasizes that peer review reports must provide specific, detailed analysis rather than conclusory statements. Vague descriptions of injuries without proper context fail to establish a prima facie case for denying medical necessity, as seen in other medical necessity reversals where insufficient peer review documentation led to unfavorable outcomes for insurers.
Legal Update (February 2026): Since this 2011 analysis of peer review standards, New York’s Department of Financial Services has amended various no-fault regulations and fee schedules that may affect peer review requirements and medical necessity determinations. Additionally, subsequent appellate decisions may have further refined the standards for adequate peer review reports in medical necessity disputes. Practitioners should verify current regulatory provisions and recent case law developments when evaluating peer review adequacy.
