Key Takeaway
Court ruling demonstrates that properly supported independent medical examinations can establish lack of medical necessity, but opposing medical affidavits may create triable issues of fact.
Understanding Medical Necessity in No-Fault Insurance Disputes
Medical necessity determinations form the cornerstone of New York No-Fault Insurance Law disputes. Insurance companies frequently challenge healthcare providers’ claims by arguing that certain treatments were not medically necessary, often relying on independent medical examinations (IMEs) to support their position. However, as demonstrated in recent appellate decisions, the quality of evidence presented and the procedural requirements can significantly impact the outcome of these disputes.
The case of Huntington Regional Chiropractic v Truck Insurance Exchange illustrates the delicate balance courts must strike when evaluating competing medical opinions. While insurers may present seemingly strong IME reports, healthcare providers retain the right to challenge these determinations with their own medical evidence, potentially creating disputes that require trial resolution rather than summary judgment.
Jason Tenenbaum’s Analysis:
Huntington Regional Chiropractic, P.C. v Truck Ins. Exch., 2015 NY Slip Op 51068(U)(App. Term 2d Dept. 2015)
“In support of its motion, defendant submitted, among other things, two independent medical examination reports, one from a chiropractor and one from an orthopedist, which set forth a factual basis and a medical rationale for the examiners’ determination that there was a lack of medical necessity for the respective services provided (see Total Equip., LLC v Praetorian Ins. Co., 34 Misc 3d 145, 2012 NY Slip Op 50155 ). However, the medical affidavits submitted by plaintiffs in opposition were sufficient to raise a triable issue of fact as to the medical necessity of the claims at issue”
Were there contemporaneous notes? Was there anything in admissible form? Did Defendant preserve appropriate hearsay and other evidentiary objections?
Key Takeaway
This decision highlights critical procedural considerations in medical necessity disputes. While well-documented IME reports can provide strong evidence for insurers, healthcare providers can effectively counter with proper medical affidavits. The case also raises important questions about evidence foundation requirements and whether defendants adequately preserve evidentiary objections, which can significantly impact case outcomes.
Legal Update (February 2026): Since this post’s publication in 2015, New York’s medical necessity standards under Insurance Law § 5106 may have been subject to regulatory amendments, updated examination protocols, or revised evidentiary requirements for IME reports. Practitioners should verify current provisions regarding medical necessity determinations, as procedural requirements and documentation standards for both insurers and healthcare providers may have evolved significantly over the past decade.
