Key Takeaway
Court ruling clarifies that insurance companies can raise fee schedule defenses without specific details in denial forms, contrary to recent AAA arbitration trends.
Fee Schedule Defense Requirements: Court Rejects Specificity Demands
New York’s no-fault insurance system operates under strict procedural rules that govern how insurance companies must handle claims denials. One area of frequent dispute involves fee schedule defenses, where insurers argue that medical providers charged more than the allowable amounts under workers’ compensation fee schedules. A recent appellate decision provides important clarity on how much detail insurers must include when raising these defenses in their initial claim denials.
The tension often arises when medical providers argue that insurers waived their right to contest fees by not providing sufficient specificity in their denial forms. This procedural argument has gained traction in some arbitration settings, but the courts have taken a different view. Understanding these requirements is crucial for both providers and insurers navigating New York No-Fault Insurance Law.
Jason Tenenbaum’s Analysis:
Renelique v Tri State Consumers Ins. Co., 2016 NY Slip Op 50866(U)(App. Term 2d Dept, 2016)
“Plaintiff’s argument—that defendant is precluded from raising its defense that the fees charged exceeded the amount allowed by the workers’ compensation fee schedule because defendant’s denial of claim form did not set forth this defense with sufficient particularity—lacks merit (see A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779 ).”
I have seen the new trend in AAA arbitration where a fee schedule defense based upon 8 units paid to another provider must be raised with specificity, i.e., the other provider to whim the units were paid. This case clearly states that this line of thinking is wrong on the law. I assume it will take the Appellate Division to convince AAA to follow the law.
Key Takeaway
The Appellate Term firmly rejected arguments that fee schedule defenses must be raised with extreme specificity in denial forms. Unlike some arbitration trends requiring detailed information about payments to other providers, the law simply requires that the defense be set forth - not that every supporting detail be included in the initial denial.
This ruling has broader implications for how denial requirements intersect with various no-fault defenses, similar to issues that arise with medical necessity disputes and fee schedule timing requirements.
Legal Update (February 2026): Since this 2016 post, New York’s no-fault fee schedules and procedural requirements for claim denials may have been subject to regulatory amendments or updates to the Insurance Law. Practitioners should verify current provisions regarding the specificity required for fee schedule defenses in denial forms, as procedural standards and fee schedule regulations are periodically revised by the Department of Financial Services.
