Triable issue of fact through another IME in a different specialty

Competing Medical Evidence in No-Fault Insurance Disputes

In New York no-fault insurance litigation, medical necessity disputes frequently hinge on the weight and credibility of competing expert medical opinions. When insurance carriers deny claims based on Independent Medical Examinations (IMEs) or peer review reports, healthcare providers must present substantial medical evidence to create triable issues of fact. The strategic question becomes: what type of medical rebuttal evidence will courts deem sufficient to overcome summary judgment?

The Second Department Appellate Term’s decision in Brooklyn Chiropractic & Sports Therapy, P.C. v A. Central Ins. Co. addresses this critical evidentiary issue. The case illustrates an important distinction in how courts evaluate different types of medical denial evidence—specifically, the different standards applied when rebutting IME reports versus peer review reports. This distinction can determine whether a provider’s case survives summary judgment or faces dismissal.

Understanding these evidentiary standards is essential for healthcare providers navigating the complex procedural requirements of New York’s no-fault system, where the type and quality of opposing medical evidence can make or break a claim for payment.

Case Background

Brooklyn Chiropractic & Sports Therapy, P.C. sought payment for services rendered to an automobile accident patient. The insurance carrier, A. Central Insurance Co., denied twelve separate claims for lack of medical necessity. Eleven of these denials were based on an IME report, while the twelfth relied on a peer review report. When the provider sued for payment, the insurance company moved for summary judgment, submitting the medical reports supporting its denials.

The healthcare provider responded with its own IME report, conducted by a different physician one day after the insurance carrier’s examination. This competing examination reached opposite conclusions about the medical necessity of the disputed treatments. The trial court needed to determine whether these dueling expert opinions created factual questions requiring trial, or whether the insurance company’s evidence was sufficient to warrant judgment as a matter of law.

Jason Tenenbaum’s Analysis:

Brooklyn Chiropractic & Sports Therapy, P.C. v A. Cent. Ins. Co., 2013 NY Slip Op 50904(U)(App. Term 2d Dept. 2013)

(1) “Defendant also submitted an affirmed report of an independent medical examination (IME) with respect to 11 of the 12 claims, and a peer review report with respect to the 12th, each of which set forth a factual basis and medical rationale for the conclusion that the services in question were not medically necessary.”

(2) “In opposition to defendant’s motion, plaintiff submitted an affirmed report of an IME, conducted by a different doctor one day after the IME performed by defendant’s doctor. The IME report submitted by plaintiff contradicted the findings of defendant’s IME report and was sufficient to raise a triable issue of fact as to the medical necessity of the 11 claims which had been denied based upon defendant’s IME report”

(3) “However, plaintiff failed to offer any medical evidence to rebut the conclusions of defendant’s peer review report, which established a lack of medical necessity for the 12th claim”

This is similar to Hillcrest v. State Farm, where an IME report defeated the findings of the peer review report.  Yet, note how the conflicting IME reports had not effect on the claim that was denied, based upon the peer report.

Legal Significance

This decision establishes an important procedural framework for medical necessity disputes in New York no-fault litigation. The court’s differential treatment of IME-based denials versus peer review-based denials reflects the evidentiary burden healthcare providers must meet when challenging insurance carrier determinations.

When an insurance company relies on an IME report to deny coverage, courts recognize that conflicting medical opinions from qualified examiners create credibility questions inappropriate for resolution on summary judgment. The timing and proximity of competing examinations become relevant but not dispositive—here, the provider’s IME conducted just one day after the carrier’s examination was deemed sufficient to raise factual issues requiring trial resolution.

However, the court’s treatment of the peer review report highlights a critical distinction. While IME reports can be countered with competing IME reports, peer review reports require specific, substantive medical rebuttal. Simply submitting another physician’s examination findings without directly addressing the peer reviewer’s medical rationale proves insufficient. This reflects the specialized nature of peer review, which analyzes treatment necessity based on accepted medical protocols and standards rather than patient examination alone.

The decision also reinforces the principle that summary judgment standards in medical necessity cases require courts to assess whether genuine factual disputes exist. When medical professionals reach opposing conclusions based on their examinations and professional judgment, these disputes generally must proceed to trial where credibility and weight of evidence can be properly evaluated.

Practical Implications for Healthcare Providers and Attorneys

Healthcare providers challenging medical necessity denials must carefully tailor their rebuttal strategy to the type of evidence the insurance carrier presents. When facing IME-based denials, obtaining a competing IME from a qualified physician in the same or related specialty can successfully create triable issues of fact. The temporal proximity of examinations, while potentially relevant to credibility, does not preclude the court from recognizing genuine medical disputes.

For peer review-based denials, providers must do more than submit general medical evidence. The rebuttal must specifically address the peer reviewer’s conclusions, methodology, and medical rationale. This typically requires the provider’s expert to review the peer review report itself and explain why the reviewer’s conclusions are medically or factually flawed. Generic affidavits asserting medical necessity without engaging the peer reviewer’s specific findings will prove inadequate.

Insurance defense attorneys should consider strategic use of peer review reports for certain claims, recognizing the heightened burden providers face in rebutting this evidence. Conversely, plaintiffs’ counsel must ensure their medical experts specifically reference and rebut peer review findings rather than simply providing independent medical opinions.

Related Articles

• Why conclusory affidavits fail in opposing medical necessity summary judgment motions
• Effective strategies for peer review rebuttals in no-fault insurance cases
• How poorly drafted medical affidavits fail against insurance necessity motions
• Understanding when conclusory affidavits are insufficient to defeat lack of medical necessity motions
• New York No-Fault Insurance Law

Legal Update (February 2026): Since 2013, New York’s no-fault regulations have undergone several amendments affecting IME procedures, peer review standards, and medical necessity determinations. Practitioners should verify current provisions regarding IME timing requirements, qualified examiner credentials, and the evidentiary standards for rebutting peer review reports, as procedural and substantive requirements may have been modified.