Key Takeaway
NY court ruling shows insurance expert testimony needs factual basis and medical rationale to prove lack of medical necessity in no-fault cases.
Understanding Medical Necessity Standards in New York No-Fault Insurance Cases
When insurance companies deny coverage for medical services, they must provide compelling evidence that the treatments were not medically necessary. This burden of proof becomes particularly challenging when their expert testimony lacks substance. A 2013 New York appellate court decision illustrates the critical standards that expert witnesses must meet to successfully challenge medical necessity in no-fault insurance disputes.
The case of Radiology Today, P.C. v Travelers Ins. Co. demonstrates how courts evaluate the adequacy of expert testimony and highlights why insurance companies cannot rely solely on conclusory opinions or peer review reports. This ruling has significant implications for healthcare providers seeking reimbursement and for insurance companies defending medical necessity challenges.
Jason Tenenbaum’s Analysis:
Radiology Today, P.C. v Travelers Ins. Co., 2013 NY Slip Op 50849(U)(App. Term 2d Dept. 2013)
“Since defendant’s expert’s testimony did not include a factual basis or medical rationale for her opinion, it was insufficient to establish that there was a lack of medical necessity for the services rendered (see A-Quality Med. Supply v GEICO Gen. Ins. Co., Misc 3d , 2013 NY Slip Op 23088 ; PSW Chiropractic Care, P.C. [*2]v Maryland Cas. Co., 32 Misc 3d 144, 2011 NY Slip Op 51719 ). Additionally, a peer review report, unlike a witness, is not subject to cross-examination and is not admissible by defendant to prove lack of medical necessity (see A-Quality Med. Supply, Misc 3d , 2013 NY Slip Op 23088). Thus, the Civil Court’s determination that defendant had not established that the services at issue were not medically necessary, could have been reached under a fair interpretation of the evidence”
So why bring the treating doctor to court?
Key Takeaway
Insurance companies cannot simply present bare conclusions from experts to deny medical necessity claims. Expert testimony must include specific factual foundations and clear medical reasoning. Additionally, peer review reports alone are insufficient because they cannot be cross-examined, making live expert testimony essential for establishing lack of medical necessity in court proceedings.
Legal Update (February 2026): Since this 2013 decision, New York’s no-fault insurance regulations have undergone several revisions, including updates to medical necessity standards, expert witness requirements, and procedural rules for insurance denials. Practitioners should verify current provisions in 11 NYCRR Part 65 and recent appellate decisions, as evidentiary standards and burden of proof requirements may have evolved significantly over the past thirteen years.
