Key Takeaway
Court ruling establishes that IME reports must provide factual basis and medical rationale when claiming injuries are resolved in no-fault insurance cases.
Understanding IME Report Requirements in No-Fault Insurance Cases
In New York’s no-fault insurance system, Independent Medical Examinations (IMEs) play a crucial role when insurance companies seek to deny coverage based on lack of medical necessity. These examinations, conducted by doctors hired by the insurance carrier, are often used to dispute ongoing treatment claims. However, a significant court ruling has established important standards for what constitutes a legally sufficient IME report.
The case of Premier Health Choice Chiropractic, P.C. v Praetorian Ins. Co. represents a potentially groundbreaking development in New York No-Fault Insurance Law. This decision may mark the first time a court has explicitly stated the evidentiary requirements for IME reports when insurance companies claim that injuries have resolved and treatment is no longer medically necessary.
This ruling has significant implications for both healthcare providers seeking payment for services and insurance companies defending against no-fault claims. The decision could influence how courts evaluate medical necessity reversals and set new standards for the sufficiency of medical evidence in these disputes.
Jason Tenenbaum’s Analysis:
Premier Health Choice Chiropractic, P.C. v Praetorian Ins. Co., 2013 NY Slip Op 51802(U)(App. Term 1st Dept. 2013)
“sworn independent medical examination (IME) report of its examining chiropractor, which set forth a factual basis and medical rationale for the chiropractor’s stated conclusion that the assignor’s injuries were resolved and that the chiropractic treatment giving rise to plaintiff’s no-fault claim lacked medical necessity.”
Perhaps this is the first time that the Court has opined that a lack of medical necessity defense on an IME case requires proof that a factual basis and medical rational for showing that injuries were resolved.
Key Takeaway
This ruling establishes that insurance companies cannot simply rely on conclusory statements from IME doctors. Instead, they must provide detailed factual foundations and medical reasoning when claiming that a patient’s injuries have resolved. This standard could significantly impact how courts evaluate the sufficiency of medical evidence in no-fault insurance disputes, potentially making it more difficult for carriers to successfully deny ongoing treatment claims without substantial supporting documentation.
Legal Update (February 2026): Since this post’s publication in 2013, New York’s no-fault insurance regulations and IME requirements have undergone several revisions, including updates to 11 NYCRR 65 and potential amendments to fee schedules and procedural standards. The evidentiary standards for IME reports discussed in Premier Health Choice may have been further refined through subsequent appellate decisions and regulatory changes. Practitioners should verify current IME reporting requirements and medical necessity standards under the most recent Insurance Department regulations and case law.
