Key Takeaway
Court improperly searched record to grant defendant summary judgment on medical necessity when plaintiff never moved on that issue, violating procedural fairness.
This article is part of our ongoing medical necessity coverage, with 170 published articles analyzing medical necessity issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
No-fault insurance litigation requires strict adherence to procedural rules, particularly when courts consider summary judgment motions. One of the fundamental principles of New York civil procedure is that parties must be given fair notice and opportunity to be heard on issues raised in litigation. When a healthcare provider moves for summary judgment seeking payment for services rendered, the scope of that motion defines what issues the court should properly decide. A recent Appellate Term decision from the Second Department highlights a critical procedural misstep that can unfairly disadvantage healthcare providers when courts exceed the boundaries of the relief actually requested.
The decision in Healing Art Acupuncture, P.C. v Allstate Insurance Co. addresses the limits of judicial discretion in granting summary judgment to non-moving parties. While courts possess inherent authority to search the record and grant relief to parties who did not formally move for it, this power is not unlimited. When exercised improperly, it can create procedural unfairness by deciding issues that one party had no reason to anticipate defending against.
Case Background
In Healing Art Acupuncture, the plaintiff healthcare provider filed a motion for summary judgment against Allstate Insurance Company to recover no-fault benefits for medical services rendered. The plaintiff’s motion focused on establishing the prima facie elements of a no-fault claim: proof of services rendered, proof of mailing the claim forms, and proof that the bills remained unpaid. Notably absent from the plaintiff’s motion was any argument regarding the medical necessity of the services provided after a specific date.
Rather than simply deciding the motion as presented, the trial court sua sponte searched the record and found grounds to grant summary judgment to the defendant insurance company on the issue of medical necessity for services rendered after November 20, 2009. This judicial initiative created a procedural problem because medical necessity was never part of the plaintiff’s affirmative case, and therefore the plaintiff had not submitted evidence specifically addressing this defense.
Jason Tenenbaum’s Analysis:
Healing Art Acupuncture, P.C. v Allstate Ins. Co., 2015 NY Slip Op 51670(U)(App. Term 2d Dept. 2015)
“While the court has the power to award summary judgment to a nonmoving party predicated upon a motion for that relief by another party (see Dunham v Hilco Constr. Co., 89 NY2d 425 ), here the issue of medical necessity was not the subject of plaintiff’s motion for summary judgment (see Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 ). As a result, the court improvidently exercised its discretion when it searched the record and awarded defendant summary judgment dismissing the complaint insofar as it sought to recover for services rendered after November 20, 2009″
Search of the record was inappropriate. It makes sense in this case as Plaintiff has no reason to believe (s) he had to proffer sufficient evidence to show the services were medically necessary,
Legal Significance
The Appellate Term’s reversal reinforces important procedural protections in New York civil practice. While Dunham v Hilco Construction Co., 89 NY2d 425, established that courts can award summary judgment to non-moving parties in appropriate circumstances, the Appellate Term clarified that this authority has limits. The court cannot search the record to grant relief on defenses that were never raised as affirmative claims requiring response.
This principle protects the fundamental fairness of motion practice. When a plaintiff moves for summary judgment on payment of no-fault benefits, the plaintiff naturally focuses evidence and argument on the elements of the prima facie case. If the defendant wishes to assert affirmative defenses like lack of medical necessity, the defendant should cross-move or file their own motion, giving the plaintiff fair notice and opportunity to respond with appropriate evidence.
The decision cited Mary Immaculate Hospital v Allstate Insurance Co., 5 AD3d 742, which similarly held that courts should not search the record to award defendants summary judgment on issues not properly before the court. This line of cases establishes a consistent principle that procedural fairness requires parties to know what issues they must address with evidence and argument.
Practical Implications for Attorneys and Litigants
This ruling has important strategic implications for both healthcare providers and insurance companies in no-fault litigation. For plaintiff healthcare providers, it confirms that when moving for summary judgment on payment issues, they need not anticipate and preemptively address every possible affirmative defense. The burden remains on the defendant to raise those defenses through proper motion practice or opposition papers.
For insurance companies defending no-fault claims, the decision clarifies that passive reliance on the court to search the record is insufficient. If the insurer wishes to assert lack of medical necessity or other affirmative defenses, it must do so through a cross-motion or by properly raising the issue in opposition papers. Simply hoping the court will independently discover grounds for dismissal will not satisfy procedural requirements.
This decision also serves as a reminder to trial courts about the proper scope of their sua sponte authority. While courts have power to prevent injustice by searching the record in appropriate cases, this power must be exercised with restraint to preserve the adversarial system’s core principle that parties should know what issues they must defend against.
Key Takeaway
Courts cannot sua sponte search records to grant summary judgment on issues not raised in the motion. When medical necessity isn’t the subject of a plaintiff’s motion, the court acts improperly by independently examining evidence to dismiss claims on that ground. This protects healthcare providers from unexpected procedural disadvantages in no-fault litigation.
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Medical Necessity Disputes in No-Fault Insurance
Medical necessity is the most common basis for no-fault claim denials in New York. Insurers hire peer reviewers to opine that treatment was not medically necessary, shifting the burden to providers and claimants to demonstrate otherwise. The legal standards for establishing and rebutting medical necessity — including the sufficiency of peer review reports, the qualifications of reviewing physicians, and the evidentiary burdens at arbitration and trial — are the subject of extensive case law. These articles provide detailed analysis of medical necessity litigation strategies and court decisions.
170 published articles in Medical Necessity
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Frequently Asked Questions
What is a medical necessity denial in no-fault insurance?
A medical necessity denial occurs when the insurer's peer reviewer determines that treatment was not medically necessary based on a review of the patient's medical records. The peer reviewer writes a report explaining why the treatment does not meet the standard of medical necessity. To challenge this denial, the provider or claimant must present medical evidence — typically an affirmation from the treating physician — explaining why the treatment was necessary and rebutting the peer review findings.
How do you challenge a peer review denial?
To overcome a peer review denial, you typically need an affirmation or affidavit from the treating physician that specifically addresses and rebuts the peer reviewer's findings. The treating physician must explain the medical rationale for the treatment, reference the patient's clinical findings, and demonstrate why the peer reviewer's conclusions were incorrect. Generic or conclusory statements are insufficient — the response must be detailed and fact-specific.
What criteria determine medical necessity for no-fault treatment in New York?
Medical necessity is evaluated based on whether the treatment is appropriate for the patient's diagnosed condition, consistent with accepted medical standards, and not primarily for the convenience of the patient or provider. Peer reviewers assess factors including clinical findings, diagnostic test results, treatment plan consistency with the diagnosis, and whether the patient is showing functional improvement. Treatment that is excessive, experimental, or unsupported by objective findings may be deemed not medically necessary.
Can an insurer cut off no-fault benefits based on one IME?
Yes, an insurer can discontinue benefits after a single IME doctor concludes that further treatment is not medically necessary or that the claimant has reached maximum medical improvement. However, the IME report must be sufficiently detailed and the denial must be issued within 30 days under 11 NYCRR §65-3.8(c). The treating physician can submit a rebuttal affirmation explaining why continued treatment is necessary, forming the basis for challenging the cut-off at arbitration.
What is a peer review in no-fault insurance?
A peer review is a paper-based evaluation where a licensed medical professional reviews the patient's records and renders an opinion on whether the billed treatment was medically necessary. Unlike an IME, the peer reviewer does not examine the patient. The peer review report must be detailed, address the specific treatment at issue, and explain the medical rationale for the opinion. Generic or boilerplate peer reviews that fail to address the patient's individual clinical presentation may be found insufficient.
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About the Author
Jason Tenenbaum, Esq.
Jason Tenenbaum is the founding attorney of the Law Office of Jason Tenenbaum, P.C., headquartered at 326 Walt Whitman Road, Suite C, Huntington Station, New York 11746. With over 24 years of experience since founding the firm in 2002, Jason has written more than 1,000 appeals, handled over 100,000 no-fault insurance cases, and recovered over $100 million for clients across Long Island, Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, the Bronx, and Staten Island. He is one of the few attorneys in the state who both writes his own appellate briefs and tries his own cases.
Jason is admitted to practice in New York, New Jersey, Florida, Texas, Georgia, and Michigan state courts, as well as multiple federal courts. His 2,353+ published legal articles analyzing New York case law, procedural developments, and litigation strategy make him one of the most prolific legal commentators in the state. He earned his Juris Doctor from Syracuse University College of Law.
Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
If you need legal help with a medical necessity matter, contact our office at (516) 750-0595 for a free consultation. We serve clients throughout Long Island (Huntington, Babylon, Islip, Brookhaven, Smithtown, Riverhead, Southampton, East Hampton), Nassau County (Hempstead, Garden City, Mineola, Great Neck, Manhasset, Freeport, Long Beach, Rockville Centre, Valley Stream, Westbury, Hicksville, Massapequa), Suffolk County (Hauppauge, Deer Park, Bay Shore, Central Islip, Patchogue, Brentwood), Queens, Brooklyn, Manhattan, the Bronx, Staten Island, and Westchester County. Prior results do not guarantee a similar outcome.
