Key Takeaway
Court ruling clarifies IME notification requirements in no-fault cases, with defense succeeding in cutting off acupuncture benefits through proper medical examination procedures.
Independent Medical Examinations (IMEs) serve as a critical tool for insurance companies to evaluate the ongoing medical necessity of treatments in New York no-fault insurance cases. When an insurer questions whether continued treatment is warranted, they can schedule an IME to obtain an independent assessment of the claimant’s condition and treatment needs.
This case from the Appellate Term demonstrates how insurers can successfully terminate benefits when they follow proper procedures and obtain supportive medical opinions. The decision also addresses an important procedural question about notification requirements that has implications for future medical necessity reversals. Understanding these requirements is essential for both providers and insurers navigating no-fault disputes.
Jason Tenenbaum’s Analysis:
V.S. Care Acupuncture PC v MVAIC, 2015 NY Slip Op 50350(U)(App. Term 1st Dept. 2015)
Defendant MVAIC made a prima facie showing of entitlement to judgment as a matter of law by demonstrating that it timely denied plaintiff’s first-party no-fault claims based on a sworn independent medical examination (IME) report of its examining acupuncturist, which set forth a factual basis and medical rationale for his stated conclusion that the assignor’s injuries were resolved and that there was no need for further acupuncture treatment (see Utica Acupuncture, P.C. v Interboro Ins. Co., 39 Misc 3d 139, 2013 NY Slip Op 50643 ). Contrary to the conclusion reached below, defendant was not required to provide notice of the scheduled IME to plaintiff provider (see 11 NYCRR 65-1.1; 65-3.5 ,; 65-3.6;”
I am partial to this case because of Utica v. Interboro. Shout out to myself. I also sense an application of the bolded language that will find its way in a brief to the Appellate Division, First Department eventually.
Key Takeaway
The court ruled that insurance companies can successfully cut off benefits through properly conducted IMEs without notifying the healthcare provider of the examination. This procedural clarification strengthens insurers’ ability to challenge ongoing treatment necessity while potentially limiting providers’ ability to prepare for or contest IME findings that may affect their patients’ coverage.
Legal Update (February 2026): Since this 2015 post, the IME procedures and medical necessity evaluation standards referenced in 11 NYCRR 65-1 may have been subject to regulatory amendments or procedural modifications. Additionally, notification requirements under sections 65-3.5 and 65-3.6 may have evolved through subsequent regulatory updates or judicial interpretations. Practitioners should verify current provisions of the no-fault regulations and recent case law developments regarding IME protocols and benefit termination procedures.
