Key Takeaway
New York court ruling confirms insurance medical experts don't need to review all plaintiff records to establish prima facie case for lack of serious injury.
This article is part of our ongoing 5102(d) issues coverage, with 251 published articles analyzing 5102(d) issues issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
Understanding Medical Expert Requirements in No-Fault Cases
In New York’s no-fault insurance system, establishing whether an injury meets the “serious injury” threshold under Insurance Law § 5102(d) often hinges on competing medical expert opinions. A common defense strategy involves challenging the plaintiff’s injuries by arguing they don’t rise to the statutory serious injury standard. However, plaintiffs frequently counter by claiming the defense expert’s opinion is inadequate because they didn’t review certain medical records like MRIs or EMG studies.
The Brand v Evangelista decision provides important clarity on what constitutes a sufficient prima facie showing by defense experts. This ruling has significant implications for both personal injury cases and medical necessity determinations in no-fault disputes, areas where similar expert witness standards apply.
Jason Tenenbaum’s Analysis:
Brand v Evangelista, 103 AD3d 539 (1st Dept. 2013)
“efendant’s physicians required to review plaintiff’s medical records, since they detailed the specific tests they used in their personal examination of plaintiff, which revealed full range of motion (see Fuentes v Sanchez, 91 AD3d 418, 419 ; Zhijian Yang v Alston, 73 AD3d 562 ).
…is physicians did not tender any recent quantified range-of-motion measurements to demonstrate any limitations he may have had from his herniated discs, or following his second back surgery.
Point of this case is that the line: “well you did not look at the MRI’s or EMG’s” should not be fatal to an insurance carrier’s expert who opines on the lack of medical necessity, lack of causal relationship or non existence of a statutory serious injury.
Key Takeaway
Defense medical experts can establish a prima facie case for lack of serious injury without reviewing all plaintiff medical records, provided they conduct thorough physical examinations and document specific objective findings. This principle applies equally to medical necessity reversals where similar expert testimony standards govern insurance coverage decisions.
Legal Update (February 2026): Since this 2013 post, New York courts have continued to refine standards for medical expert testimony in serious injury determinations, and Insurance Law § 5102(d) has been subject to ongoing judicial interpretation that may affect the sufficiency requirements for prima facie showings. Practitioners should verify current case law developments and any regulatory updates that may have modified expert witness standards or medical record review requirements in no-fault serious injury cases.
Related Articles
Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
Keep Reading
More 5102(d) issues Analysis
Significant limitation v. permanent consequential, again
New York court ruling creates apparent contradiction in no-fault threshold requirements for significant limitation vs. permanent consequential limitation cases.
May 22, 2021MUA is dangerous
Court finds MUA treatment too aggressive without proper foundation. Expert testimony on medical necessity prevails in no-fault insurance dispute.
Mar 17, 2021Lost to Dr. Bhatt
Appellate Term affirms Civil Court ruling against medical provider in no-fault case where defendant failed to prove services weren't medically necessary.
Nov 28, 2015Unrebutted doctor’s testimony insufficient to prove the services lacked a medical necessity
NY court ruling shows insurance expert testimony needs factual basis and medical rationale to prove lack of medical necessity in no-fault cases.
May 29, 2013Pan Chiro sightings
Pan Chiro case continues to be cited in NY no-fault insurance medical necessity disputes, showing how poor affidavits of merit fail against proper peer review reports.
Oct 8, 2010The need for contemporaneous records
Second Department clarifies that contemporaneous medical examinations aren't required to defeat summary judgment motions under Insurance Law § 5102(d).
Apr 10, 2019Common Questions
Frequently Asked Questions
What is the serious injury threshold under Insurance Law §5102(d)?
New York Insurance Law §5102(d) defines 'serious injury' as a personal injury that results in death, dismemberment, significant disfigurement, a fracture, loss of a fetus, permanent loss of use of a body organ, member, function or system, permanent consequential limitation of use of a body organ or member, significant limitation of use of a body function or system, or a medically determined injury that prevents the person from performing substantially all of their daily activities for at least 90 of the first 180 days following the accident.
Why does the serious injury threshold matter?
In New York, you cannot sue for pain and suffering damages in a motor vehicle accident case unless your injuries meet the serious injury threshold. This is a critical hurdle in every car accident lawsuit. Insurance companies aggressively challenge whether plaintiffs meet this threshold, often relying on IME doctors who find no objective limitations. Successfully establishing a serious injury requires detailed medical evidence, including quantified range-of-motion findings and correlation to the accident.
What is a medical necessity denial in no-fault insurance?
A medical necessity denial occurs when the insurer's peer reviewer determines that treatment was not medically necessary based on a review of the patient's medical records. The peer reviewer writes a report explaining why the treatment does not meet the standard of medical necessity. To challenge this denial, the provider or claimant must present medical evidence — typically an affirmation from the treating physician — explaining why the treatment was necessary and rebutting the peer review findings.
How do you challenge a peer review denial?
To overcome a peer review denial, you typically need an affirmation or affidavit from the treating physician that specifically addresses and rebuts the peer reviewer's findings. The treating physician must explain the medical rationale for the treatment, reference the patient's clinical findings, and demonstrate why the peer reviewer's conclusions were incorrect. Generic or conclusory statements are insufficient — the response must be detailed and fact-specific.
What criteria determine medical necessity for no-fault treatment in New York?
Medical necessity is evaluated based on whether the treatment is appropriate for the patient's diagnosed condition, consistent with accepted medical standards, and not primarily for the convenience of the patient or provider. Peer reviewers assess factors including clinical findings, diagnostic test results, treatment plan consistency with the diagnosis, and whether the patient is showing functional improvement. Treatment that is excessive, experimental, or unsupported by objective findings may be deemed not medically necessary.
Was this article helpful?
About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a 5102(d) issues matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.