An IME no-show case from the 9th and 10th

Understanding IME No-Show Cases: Proper Documentation Makes the Difference

Independent Medical Examinations (IMEs) are a cornerstone of New York No-Fault Insurance Law, allowing insurers to verify medical claims through independent physician evaluations. When claimants fail to appear for scheduled IMEs, insurers can deny claims - but only if they can prove proper notice was given and procedures were followed.

The case East 75th St. Diagnostic Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. from the 9th and 10th Judicial Districts provides a textbook example of how insurers should document IME no-show situations to successfully defend their claim denials.

When insurance carriers rely on IME no-show defenses, they must establish three critical elements: proper notice of the examination was sent to the claimant, the claimant failed to appear, and the denial of claims was timely communicated. Each element requires specific documentary proof. Failure to establish any single element can result in the carrier being deemed to have waived its right to assert the defense, leaving it liable for payment despite the claimant’s non-cooperation.

The standards for proving these elements vary somewhat between judicial departments, with the First Department applying particularly stringent requirements under the Unitrin line of cases. However, as this decision from the 9th and 10th Judicial Districts demonstrates, carriers who methodically document their procedures and maintain proper records can successfully establish IME no-show defenses even under rigorous scrutiny.

Case Background

East 75th Street Diagnostic Imaging, P.C., a medical provider, sued New York Central Mutual Fire Insurance Company seeking payment for diagnostic imaging services provided to an injured patient. The insurance carrier denied the claims based on the patient’s failure to appear for scheduled Independent Medical Examinations.

The provider challenged the denial, arguing that the insurer failed to adequately prove that IME notices were properly sent or that the patient actually failed to appear. The case proceeded to motion practice, where the court evaluated whether the insurance company had established its IME no-show defense through competent evidence. The quality and completeness of the insurer’s documentation would determine the outcome.

Jason Tenenbaum’s Analysis

East 75th St. Diagnostic Imaging, P.C. v New York Cent. Mut. Fire Ins. Co.
35 Misc.3d 126(A)

1. “The affidavit sufficiently established that the IME notices had been sent to plaintiff’s assignor in accordance with NCEI’s standard office practices and procedures”

2. “Defendant also submitted affidavits and an affirmation by the doctors who were to perform the IMEs, which established that the assignor had failed to appear for the duly scheduled IMEs”

3. “In addition, defendant sufficiently established that the denial of claim forms had been timely mailed in accordance with defendant’s standard office practices and procedures”

Compare this with a typical First Department per curiam construing Unitrin.

Legal Significance

This decision illustrates the comprehensive approach courts require for establishing IME no-show defenses. The case breaks down the proof requirements into three distinct components, each requiring separate documentation. First, the insurer must prove the IME scheduling notices were properly mailed. This requires an affidavit from someone with knowledge of the office’s mailing procedures, establishing that notices were sent according to standard practices. Generic assertions are insufficient—the affidavit must demonstrate actual adherence to established procedures.

Second, the insurer must prove the claimant actually failed to appear. This seemingly obvious requirement has tripped up many carriers. An affidavit from the examining physician or the physician’s office staff confirming non-appearance provides the necessary proof. The physician’s personal knowledge of the non-appearance distinguishes this proof from hearsay or speculation. Courts reject attempts to prove non-appearance through claims file notes or other indirect evidence lacking personal knowledge.

Third, the insurer must establish timely mailing of denial forms. This element often receives less attention but remains equally critical. Under New York’s no-fault regulations, carriers must deny claims within specific timeframes. Proving timely denial requires the same type of mailing affidavit used to establish notice—testimony from someone with knowledge of office mailing procedures confirming the denials were sent according to standard practices.

Practical Implications

For insurance carriers and defense counsel, this decision provides a clear roadmap for documenting IME no-show situations. From the outset of claim handling, carriers should implement procedures ensuring they can later prove each required element. This means maintaining detailed records of when IME notices are sent, who sends them, and what standard procedures were followed. Similarly, carriers should obtain and preserve written confirmation from examining physicians documenting non-appearance.

The decision also highlights the value of using third-party IME scheduling companies with established procedures. The reference to “NCEI’s standard office practices and procedures” suggests the carrier used an outside vendor to schedule examinations. These vendors typically maintain sophisticated tracking systems and can provide detailed affidavits about their procedures. Their independence from the insurance carrier may also enhance credibility with courts skeptical of self-serving carrier testimony.

For healthcare providers and plaintiffs’ attorneys, this decision illustrates the elements they must challenge when contesting IME no-show defenses. Simply arguing that the claimant never received notice or claims to have appeared is insufficient without evidence. Providers need to identify specific deficiencies in the carrier’s proof—such as lack of personal knowledge by affiants, gaps in the documented procedures, or failures to establish adherence to those procedures.

Key Takeaway

This case demonstrates that insurers can successfully defend IME no-show claims by providing comprehensive documentation: affidavits establishing standard mailing procedures for notices, physician affirmations confirming non-appearance, and proof of timely denial mailings. This thorough approach contrasts with typical First Department decisions that often apply stricter Unitrin standards for claim denials.

Legal Update (February 2026): Since this 2012 post, New York’s no-fault regulations and IME procedures may have been subject to amendments, including potential changes to notice requirements, documentation standards, and denial procedures. The Insurance Department has periodically updated regulations governing IME scheduling and no-show protocols. Practitioners should verify current regulatory provisions under 11 NYCRR Part 65 and recent case law interpretations when handling IME no-show cases.

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