Key Takeaway
Court ruling demonstrates that a treating physician's letter of medical necessity can create sufficient factual disputes to defeat summary judgment in no-fault insurance cases.
Understanding Medical Necessity in No-Fault Insurance Disputes
In New York no-fault insurance law, one of the most contentious battlegrounds involves disputes over medical necessity. Insurance carriers frequently deny claims by arguing that requested treatments, tests, or procedures are not medically necessary. However, healthcare providers have powerful tools at their disposal to challenge these denials, and understanding what constitutes sufficient evidence can make the difference between victory and defeat in litigation.
The Complete Radiology, P.C. v GEICO case illustrates a fundamental principle: courts will not grant summary judgment when genuine factual disputes exist regarding medical necessity. This particular ruling emerged from the Appellate Term, Second Department, and provides valuable guidance for medical providers navigating no-fault insurance disputes.
When insurance companies file motions for summary judgment, they typically rely on peer review reports or independent medical examinations to support their position that services were not medically necessary. However, providers can successfully counter these motions by presenting compelling medical evidence, even in seemingly straightforward formats like letters of medical necessity.
This case demonstrates that courts recognize the expertise of treating physicians and will give appropriate weight to their professional medical opinions when determining whether disputed facts exist. The ruling reinforces that medical necessity disputes often cannot be resolved as a matter of law and must proceed to trial where factfinders can evaluate competing medical opinions.
Jason Tenenbaum’s Analysis:
Complete Radiology, P.C. v GEICO Ins. Co., 2012 NY Slip Op 50419(U)(App. Term 2d Dept. 2012)
“the affirmed letter of medical necessity submitted by plaintiff’s assignor’s treating physician was sufficient to demonstrate that there is a triable issue of fact as to medical necessity”
See the buzz words.
Key Takeaway
The court’s emphasis on the treating physician relationship cannot be overstated. Unlike independent medical examiners or peer reviewers who may never have examined the patient, treating physicians possess intimate knowledge of the patient’s condition, medical history, and response to treatment. Their professional opinions carry significant weight in establishing factual disputes that preclude summary judgment.
For healthcare providers facing medical necessity denials, this case reinforces that well-crafted letters from treating physicians can be powerful litigation tools. While insurance carriers may present peer review reports to support their denials, treating physicians’ letters create competing narratives that courts must allow juries to resolve. This protection extends to various medical facilities, including MRI centers facing necessity challenges.
Legal Update (February 2026): Since this 2012 post, New York’s no-fault insurance regulations have undergone several amendments, including updates to medical necessity standards, peer review procedures, and summary judgment practice requirements. The fee schedules and procedural rules governing medical necessity disputes may have been modified through regulatory changes and court decisions. Practitioners should verify current provisions under 11 NYCRR Part 65 and recent Appellate Term decisions when handling medical necessity challenges.
