Key Takeaway
Insurance carriers can successfully deny no-fault claims when patients fail to appear for scheduled IMEs, provided proper procedures are followed for verification requests.
No-fault insurance carriers have specific procedural requirements they must follow when denying claims based on a patient’s failure to appear for an Independent Medical Examination (IME). This case demonstrates how insurers can successfully defend their claim denials by establishing compliance with both verification requirements and IME scheduling protocols under New York No-Fault Insurance Law.
The decision highlights three critical elements that carriers must prove: proper scheduling of IMEs, timely requests for additional verification, and appropriate timing of claim denials. When carriers follow these procedural steps correctly, courts will uphold denials even when patients simply fail to show up for their scheduled examinations.
Jason Tenenbaum’s Analysis:
“Defendant also established that the assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 ). Defendant further demonstrated that, upon receipt of the claims, it had timely mailed initial and follow-up requests for written verification (see 11 NYCRR 65-3.5 ; 65-3.8 ; St. Vincent’s Hosp. of Richmond, 50 AD3d 1123). Finally, defendant established that, upon receiving the requested verification, it had timely denied the claims at issue based upon the assignor’s failure to appear for IMEs”
This case illustrates proper procedural compliance where the first IME date was scheduled within 30 days of receiving the billing. Importantly, the billing was delayed pending additional verification, and the carrier appropriately waited to receive the verification before denying the claims based on the policy violation. This careful sequencing of events - requesting verification first, then scheduling the IME, and finally denying based on non-appearance - demonstrates the methodical approach carriers must take to ensure their denials withstand legal scrutiny.
Key Takeaway
Successful IME no-show denials require carriers to demonstrate three key elements: timely IME scheduling within regulatory requirements, proper verification requests under 11 NYCRR 65-3.5 and 65-3.8, and appropriate timing of the denial. When carriers follow this procedural sequence correctly, courts will uphold claim denials based on patient non-appearance.
Legal Update (February 2026): Since this 2016 post, the procedural requirements for IME scheduling and additional verification requests under 11 NYCRR 65-3.5 and 65-3.8 may have been subject to regulatory amendments or clarifications. The timing requirements and specific procedural steps for claim denials based on IME non-appearance should be verified against current regulations, as enforcement interpretations and compliance standards may have evolved. Practitioners should confirm current provisions in the most recent version of Part 65 before relying on the procedural analysis discussed in this post.
