Key Takeaway
Court ruling clarifies insurance carriers' burden of proof when denying MRI facility claims based on failure to provide requested verification materials.
MRI Verification Requirements: When Carriers Deny Claims for Missing Films
In New York no-fault insurance disputes, medical providers frequently face claim denials based on alleged failure to provide requested verification materials. This issue becomes particularly complex when dealing with MRI facilities and the submission of actual film images. The Radiology Today case provides important guidance on how courts evaluate these disputes and what evidence carriers must present to support their denial decisions.
Understanding the verification process is crucial for both providers and carriers operating under New York No-Fault Insurance Law. When carriers request additional verification, they must demonstrate they properly made these requests and that providers failed to respond appropriately. The burden of proof requirements for such denials have been addressed in various contexts, as seen in cases involving additional verification non-receipt.
Jason Tenenbaum’s Analysis:
Radiology Today, P.C. v New York Cent. Mut. Fire Ins. Co., 2011 NY Slip Op 52452(U)(App. Term 2d Dept. 2011)
The carrier is delaying for an MRI film from an MRI facility. What is the basis? Lack of causal relationship? Seeking to obtain the film at the workers compensation rate of $5.00 per sheet, as opposed to having to pay market rate during discovery in the personal injury matter?
Here are the facts and the holding.
“Contrary to plaintiff’s contention, the affidavit of defendant’s litigation examiner, submitted in support of defendant’s motion, established that defendant had timely mailed its requests and follow-up requests for verification (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 ; Delta Diagnostic Radiology, P.C. v Chubb [*2]Group of Ins., 17 Misc 3d 16 ), and that plaintiff had failed to provide the MRI films which, among other things, defendant’s requests for verification had sought.”
Key Takeaway
This decision reinforces that insurance carriers must provide proper documentation, typically through affidavits from litigation examiners, to prove they timely requested verification materials and that providers failed to respond. Courts will examine the evidence carefully to determine whether carriers met their burden of proof before denying claims based on verification non-receipt issues.
Legal Update (February 2026): Since this post’s publication in 2012, New York’s no-fault fee schedules and verification procedures have undergone multiple regulatory amendments. Practitioners should verify current provisions regarding MRI reimbursement rates, verification request protocols, and time limits for additional documentation requests, as these requirements may have been substantially modified through recent Insurance Department regulations.
