Key Takeaway
Easy Care Acupuncture v MVAIC case explores policy exhaustion defenses and fee schedule reductions in New York no-fault insurance acupuncture claims disputes.
Easy Care Acupuncture, PC v MVAIC, 2016 NY Slip Op 51556(U)(App. Term 1st Dept. 2016)
“While the record reflects that defendant properly paid a portion of the submitted claims for acupuncture services pursuant to the workers compensation fee schedule (see Akita Med. Acupuncture, P.C. v Clarendon Ins. Co., 41 Misc 3d 134, 2013 NY Slip Op 51860 ), triable issues remain with respect to the claims denied in whole or part by defendant on the stated basis that the maximum payment had already been made for the billed codes (see TC Acupuncture, P.C., v Tri-State Consumer Ins. Co., 52 Misc 3d 131, 2016 NY Slip Op 50978 ; Sunrise Acupuncture PC v Tri-State Consumer Ins. Co., 42 Misc 3d 151, 2014 NY Slip Op 50435 ). Defendant’s submission reveals the existence of triable issues of fact as to whether defendant partially exhausted the coverage by payments to another provider, and whether those payments were proper under the insurance department regulations. Defendant’s failure to deny the claim within 30 days does not preclude a defense that the coverage limits have been exhausted (see New York & Presbyt. Hosp. v Allstate Ins. Co., 12 AD3d 579 ).”
Starting backwards, the court questioned the priority of payment regimen. Second, the Court found issues of fact as to the fee schedule reductions. What really happened here?
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Legal Update (February 2026): Since this 2016 post, New York’s no-fault fee schedules and reimbursement regulations have been subject to periodic amendments and updates by the Department of Financial Services. Additionally, regulatory interpretations regarding policy exhaustion calculations and proper payment methodologies may have evolved through subsequent guidance or rule modifications. Practitioners should verify current fee schedule provisions and exhaustion-related regulations when handling similar coverage disputes.
