Key Takeaway
New York court requires medical evidence, not just "know it all" affidavits, to challenge IME reports in no-fault medical necessity disputes.
Court Demands Real Medical Evidence in No-Fault Cases
No-fault insurance providers frequently challenge the medical necessity of treatments through Independent Medical Examinations (IMEs). When healthcare providers want to contest these IME findings, they cannot simply submit generic affidavits from practice principals who never examined the patient. A recent Appellate Term decision demonstrates that courts are becoming more stringent about requiring actual medical evidence to create genuine disputes over medical necessity reversals.
This ruling reinforces the principle that New York no-fault insurance law requires substantive medical foundation to challenge professional IME conclusions. Healthcare providers must present qualified medical opinions based on actual patient examination or treatment records, not conclusory statements from administrators.
Jason Tenenbaum’s Analysis:
Gaetane Physical Therapy, P.C. v Great N. Ins. Co., 2015 NY Slip Op 50698(U)(App. Term 2d Dept. 2015)
“In opposition to the motion, plaintiff submitted an affidavit by its principal, who did not indicate that she had examined the assignor or otherwise offer any medical evidence to rebut the conclusions set forth in the IME report. Thus, plaintiff failed to raise a triable issue of fact as to medical necessity”
This is the “know it all” affidavit that does not offer medical evidence for post IME services. It is nice to see the Court taking a stand on this issue.
Key Takeaway
Courts are rejecting boilerplate affidavits from healthcare practice principals who lack direct patient knowledge. To successfully oppose summary judgment motions challenging medical necessity, providers must submit qualified medical opinions supported by actual examination or treatment records, not generic administrative statements.
