Key Takeaway
New York court rules that unsworn chiropractor letters lack probative value in no-fault insurance medical necessity disputes, requiring proper foundation.
Understanding Medical Necessity Evidence Standards in No-Fault Insurance Cases
Medical necessity disputes form the backbone of many New York no-fault insurance litigation cases. When healthcare providers seek reimbursement for treatments like MRI scans, insurance companies often challenge whether those services were medically necessary. The quality and admissibility of evidence supporting medical necessity claims can make or break a case.
In these disputes, healthcare providers must present compelling medical evidence to overcome an insurer’s denial. However, not all medical documentation carries equal weight in court. The form and foundation of medical reports significantly impact their probative value — their ability to actually prove what they claim to establish.
This case from the Appellate Term demonstrates a fundamental principle: medical reports must meet basic evidentiary standards to be considered by the court. Summary judgment motions in medical necessity cases often hinge on whether the submitted medical evidence can withstand judicial scrutiny. When providers fail to submit properly sworn statements or provide conclusory findings without adequate detail, they risk having their claims dismissed entirely.
Jason Tenenbaum’s Analysis:
Innovative MR Imaging, P.C. v Praetorian Ins. Co., 2013 NY Slip Op 50264(U)(App. Term 1st Dept. 2013)
“The unsworn letter report submitted by plaintiff from the assignor’s treating chiropractor was without probative value (see CPLR 2106; Pierson v Edwards, 77 AD3d 642 ), and, even if considered, the conclusory findings set forth therein were insufficient to withstand summary judgment (see CPT Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co., 18 Misc 3d 87 ).”
Key Takeaway
This decision highlights two critical evidence requirements in no-fault medical necessity cases. First, medical reports must be properly sworn under CPLR 2106 to have probative value. Second, even properly sworn reports must contain detailed, specific findings rather than conclusory statements. Healthcare providers pursuing medical necessity claims must ensure their supporting documentation meets both procedural and substantive standards to avoid dismissal.
Legal Update (February 2026): Since this 2013 post, New York’s no-fault insurance regulations and fee schedules have undergone multiple revisions that may affect medical necessity standards and procedural requirements. Additionally, CPLR 2106 affidavit requirements and Appellate Term precedents regarding medical evidence may have evolved. Practitioners should verify current provisions of the Insurance Law and updated court decisions when preparing medical necessity cases.
