Key Takeaway
Court rules that plaintiff's treating therapist affidavit failed to meaningfully address IME findings, allowing insurance company's treatment denial to stand.
In no-fault insurance litigation, healthcare providers must overcome insurance companies’ Independent Medical Examination (IME) reports when challenging treatment denials. This case demonstrates the high burden providers face when an IME concludes that a patient’s injuries have resolved and no further treatment is medically necessary.
When an insurer relies on an IME to deny coverage, the examining doctor’s findings carry significant weight in court proceedings. The provider challenging the denial must present compelling medical evidence that directly addresses and rebuts the IME physician’s specific conclusions. Generic affidavits or statements that fail to engage with the IME’s detailed findings typically prove insufficient to create a genuine dispute for trial.
This principle applies broadly across New York No-Fault Insurance Law cases, where medical necessity reversals require substantial medical evidence to succeed.
Jason Tenenbaum’s Analysis:
Rummel G. Mendoza, D.C., P.C. v Chubb Indem. Ins. Co., 2015 NY Slip Op 50900(U)(App. Term 1st Dept. 2015)
” establish that it timely denied the claims based on the independent medical examination (IME) report and follow-up report of its examining orthopedic doctor, which set forth a factual basis and medical rationale for her stated conclusion that the assignor’s injuries were resolved and that there was no need for further physical therapy treatment. In opposition, plaintiff failed to raise a triable issue. The affidavit of plaintiff’s treating physical therapist failed to meaningfully address the contrary findings made by defendant’s examining doctor, including the normal results of the range of motion testing of the assignor’s cervical and lumbar spine”
Key Takeaway
Healthcare providers cannot simply submit generic affidavits when challenging IME-based denials. The treating provider’s response must specifically address and rebut the IME physician’s clinical findings and medical conclusions. Failure to meaningfully engage with the IME’s specific objective test results, such as normal range of motion findings, will result in summary judgment for the insurance company.
