Key Takeaway
Court ruling in Five Boro Psychological v GEICO clarifies that insurers don't need to provide medical records when defending medical necessity denials in no-fault cases.
The “Mr. Five Boro” moniker has become synonymous with unfavorable outcomes for healthcare providers in New York’s no-fault insurance system. This particular case from the Appellate Term demonstrates how insurers can successfully defend against provider claims by establishing proper procedural grounds for benefit denials, even without extensive documentation requirements.
In Five Boro Psychological Services v GEICO, the court addressed a fundamental question about what evidence insurers must present when defending medical necessity denials. The ruling clarifies the evidentiary burden placed on insurance companies during summary judgment proceedings, particularly regarding peer review documentation standards.
This decision has significant implications for how providers approach litigation against insurers who deny claims based on medical necessity determinations. Understanding these procedural requirements becomes crucial when healthcare providers consider whether to pursue summary judgment motions against no-fault carriers.
Jason Tenenbaum’s Analysis:
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co., 2012 NY Slip Op 51013(U)(App. Term 2d Dept. 2012)
“In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from so much of an order as denied its motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint. The Civil Court found that defendant had established that it had timely denied the subject claims on the ground that the services at issue were not medically necessary, and that plaintiff had failed to rebut defendant’s evidence. A judgment was subsequently entered, from which this appeal is deemed to have been taken
Contrary to plaintiff’s argument on appeal, defendant was not required to annex to its motion papers copies of the medical records which were reviewed by defendant’s peer reviewer”
You always knows that when Mr. Five Boro appears, something bad will happen to the plaintiff’s bar.
Key Takeaway
This ruling establishes that insurance companies defending medical necessity denials don’t need to provide copies of the underlying medical records reviewed by their peer reviewers during summary judgment proceedings. The decision reinforces that insurers can meet their evidentiary burden through peer review reports alone, making it more challenging for providers to successfully challenge these denials in court.
Legal Update (February 2026): Since this 2012 decision, New York’s no-fault regulations have undergone significant revisions, including amendments to medical necessity review procedures and evidentiary standards for insurer defenses. The peer review documentation requirements and summary judgment standards discussed in this Five Boro case may have been modified through subsequent regulatory changes and appellate decisions. Practitioners should verify current provisions of the Insurance Law and applicable regulations when evaluating similar medical necessity disputes.
