Key Takeaway
New York court affirms Civil Court ruling that insurance company failed to prove chiropractic services weren't medically necessary in no-fault case.
Maryland Casualty’s Failed Challenge: When Insurance Companies Can’t Prove Their Case
In New York’s no-fault insurance system, insurance companies frequently challenge the medical necessity of treatments to avoid paying claims. However, they must meet their burden of proof to successfully deny coverage. The PSW Chiropractic Care case demonstrates what happens when an insurer’s evidence falls short of this standard.
This case involves a fundamental principle in no-fault litigation: the insurance company bears the burden of proving that disputed medical services were not medically necessary. When challenging treatments, insurers typically rely on Independent Medical Examinations (IMEs) and peer review reports to support their denials. The quality and credibility of this evidence is crucial, as courts will carefully scrutinize whether the insurer has met its evidentiary burden.
The title reference to “First Presbyterian, then PSW” suggests this represents part of a pattern where Maryland Casualty Company has faced similar challenges in proving medical necessity denials. Such medical necessity reversals can be costly for insurers and highlight the importance of thorough documentation when denying claims.
Jason Tenenbaum’s Analysis:
PSW Chiropractic Care, P.C. v Maryland Cas. Co., 2011 NY Slip Op 51719(U)(App. Term 2d Dept. 2011)
“In the present case, the record supports the determination of the Civil Court, based upon its assessment of the credibility of defendant’s witness and the proof
adduced at trial, that defendant failed to satisfy its burden of proving that the disputed chiropractic services were not medically necessary. As we find no basis to disturb the Civil Court’s findings, the judgment is affirmed.
Interesting dissent, but if the IME was that bad, this should have stopped at Civil Court.
Key Takeaway
This case underscores that insurance companies cannot simply rely on weak or incredible expert testimony to deny medical necessity claims. When an IME or expert witness lacks credibility, courts will find that the insurer has failed to meet its burden of proof, regardless of whether a peer report or other documentation accompanies the denial. The appellate court’s affirmance suggests the evidence was particularly problematic at the trial level.
Legal Update (February 2026): Since this 2011 analysis, New York’s no-fault insurance regulations have undergone significant revisions, including amendments to medical necessity standards, IME procedures, and evidentiary requirements for treatment denials. The fee schedules and regulatory framework governing insurer obligations when challenging medical necessity have been updated multiple times. Practitioners should verify current provisions under 11 NYCRR Part 65 and recent case law interpreting burden of proof standards in medical necessity disputes.
