Key Takeaway
Court ruling establishes that fee schedule vendors can properly substitute claims representatives in affidavits defending workers' compensation fee schedule determinations.
Understanding who can provide testimony in no-fault insurance disputes is crucial for healthcare providers seeking reimbursement. A recent appellate decision clarifies an important procedural point: insurance companies can use affidavits from their fee schedule vendors’ employees instead of their own claims representatives when defending fee schedule determinations. This ruling has significant implications for acupuncture providers and other healthcare professionals navigating reimbursement disputes under New York’s no-fault insurance system.
The case involved an acupuncture practice challenging an insurer’s fee schedule application, specifically regarding acupuncture services performed by chiropractors. The court’s decision demonstrates how insurers can effectively defend their reimbursement calculations through third-party vendor testimony.
Jason Tenenbaum’s Analysis:
Healing Art Acupuncture, P.C. v Amica Mut. Ins. Co., 2015 NY Slip Op 50078(U)(App. Term 2d Dept. 2015)
“Defendant denied plaintiff’s claims on the grounds that they exceeded the amount permitted by the workers’ compensation fee schedule, and that defendant had fully paid for the billed-for services in accordance with the fee schedule for acupuncture services performed by chiropractors. Contrary to plaintiff’s assertion, the affidavit executed by a fee schedule adjuster [*2]for defendant’s vendor, Managed Care Network, established that defendant had properly used the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which plaintiff was entitled to receive for the services at issue”
So here, you have a vendor’s affidavit establishing the merits of the fee schedule defense. Generally, this type of issue can be handled through claims representative affidavit.
Key Takeaway
This decision establishes that insurance companies can rely on affidavits from their fee schedule vendors’ adjusters to defend reimbursement determinations, rather than requiring testimony from their own claims representatives. This procedural flexibility strengthens insurers’ ability to justify their New York no-fault insurance payment decisions in court proceedings.
Legal Update (February 2026): Since this 2015 post, New York’s no-fault fee schedules and reimbursement procedures have been subject to multiple regulatory amendments and updates. Practitioners should verify current fee schedule provisions, procedural requirements for vendor testimony, and any changes to evidentiary standards that may affect reimbursement dispute proceedings.
