Key Takeaway
Court ruling establishes "objective medical explanation" requirement for no-fault insurance medical necessity defenses and highlights proper mailing procedure standards.
Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co., 2014 NY Slip Op 51766(U)(App. Term 1st Dept. 2014)
(1) The joy of mailing vendors
“In this regard, the affidavit submitted by an employee of Farmers Insurance Exchange, defendant’s claims administrator, failed to adequately describe its office mailing procedures (see Matter of Lumbermens Mut. Cas. Co. , 135 AD2d 373, 375 ), merely stating that items placed in its “mail bin” are picked up by a nonparty entity – Pitney Bowes Services, Inc. (“Pitney Bowes”) – which brings the items on a daily basis to the post office. The affiant professed no personal knowledge of, nor did she attempt to describe, the procedures utilized by Pitney Bowes to assure timely and proper delivery”
(2) On medical necessity
“Moreover, even beyond defendant’s shortcomings in proof concerning the mailing issue, the report of defendant’s peer review acupuncturist failed to set forth sufficient facts or medical rationale for his stated conclusion that further acupuncture treatment of plaintiff’s assignor was not medically necessary. That the assignor may have subjectively reported during the course of the peer review examination that she “feels worse” after three months of acupuncture treatment did not, by itself and without any objective medical explanation by the peer reviewer, eliminate all triable issues regarding the medical necessity of continued acupuncture treatment.”
This one is interesting because the Court has finally held that an objective medical explanation is necessary to support a medical necessity defense or, contrariwise, prove that there is a medical rationale for further treatment in opposition to an insurance carrier’s examination.
Related Articles
- Why Conclusory Affidavits Fail: Building Strong Opposition to Medical Necessity Summary Judgment Motions
- Effective Peer Review Rebuttals in New York No-Fault Insurance Cases
- Why Poorly Drafted Medical Affidavits Fail Against Insurance Medical Necessity Motions
- The Convergence of Medical Malpractice and No-Fault Litigation: Understanding Cross-Practice Legal Principles
- New York No-Fault Insurance Law
Legal Update (February 2026): Since this 2014 decision, New York’s no-fault regulations have undergone several amendments, particularly regarding peer review procedures under 11 NYCRR 65-3.6 and medical necessity determination standards. Additionally, mailing procedure requirements and electronic submission protocols have been updated through various regulatory changes. Practitioners should verify current provisions regarding both peer review documentation standards and proper service/mailing procedures under the most recent versions of the no-fault regulations.
