Key Takeaway
Court ruling clarifies that medical providers must meaningfully address IME findings in their rebuttals, not just submit generic affirmations to establish medical necessity.
In New York no-fault insurance litigation, medical providers frequently challenge insurance carriers’ denials of treatment based on medical necessity determinations. When carriers obtain Independent Medical Examinations (IMEs) concluding that treatment is unnecessary, providers must submit compelling medical evidence to create a triable issue of fact. However, not all medical rebuttals are created equal, and courts scrutinize whether opposing medical evidence truly addresses the specific findings in IME reports.
The Bronx Mega Care decision illustrates a common pitfall in medical necessity challenges - submitting generic medical affirmations that fail to engage with the carrier’s specific medical conclusions. This case highlights the heightened burden providers face when responding to well-documented IME reports, particularly in the context of summary judgment motions where courts examine the sufficiency of opposing evidence.
Jason Tenenbaum’s Analysis:
Bronx Mega Care Med, PLLC v Federal Ins. Co., 2015 NY Slip Op 51060(U)(App. Term 2d Dept. 2015)
“In opposition, plaintiff failed to submit medical evidence sufficient to raise a triable issue of fact as to medical necessity (see e.g. Amato v State Farm Ins. Co., 40 Misc 3d 129, 2013 NY Slip Op 51113 ). Contrary to the determination of the District Court, the opposing affirmation of plaintiff’s doctor failed to meaningfully refer to, let alone rebut, the conclusions set forth in the IME report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136, 2009 NY Slip Op 51495 ). Consequently, defendant’s motion for summary judgment dismissing the complaint should have been granted”
What is the line between meaningfully refer to and not meaningfully referred?
Key Takeaway
The distinction between “meaningful” and insufficient medical rebuttals lies in specificity and engagement with the IME’s actual findings. Courts require medical providers to directly address the conclusions and reasoning in IME reports, rather than submitting boilerplate affirmations that merely assert medical necessity without confronting the carrier’s specific medical determinations. Generic medical statements that ignore the IME’s analysis will not survive summary judgment challenges.
Legal Update (February 2026): Since this 2015 decision, New York’s medical necessity standards and rebuttal procedures under 11 NYCRR § 65-3.16 may have been subject to regulatory amendments or interpretive guidance updates. The specific requirements for medical evidence in IME rebuttals and summary judgment standards in no-fault cases should be verified against current Insurance Department regulations and recent appellate decisions.
