Key Takeaway
Court ruling on hearsay evidence in no-fault insurance fraud defenses and fee schedule denial requirements. Analysis of Box #18 denials and coverage disputes.
This article is part of our ongoing fee schedule coverage, with 152 published articles analyzing fee schedule 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.
Acupuncture Healthcare Plaza I, P.C. v 21st Century Advantage Ins. Co.,2017 NY Slip Op 50945(U)(App. Term 2d Dept. 2017)
Fee Schedule: Box #18
(1) “Contrary to plaintiff’s contention, the denial of claim forms were sufficient to advise plaintiff that defendant was partially denying plaintiff’s claims on the ground that the amount plaintiff sought to recover was not in accordance with the workers’ compensation fee schedule. Indeed, a checked box on the forms indicated that benefits were denied because the fees were not in accordance with the fee schedule (see Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 47 Misc 3d 149, 2015 NY Slip Op 50778 ; Arco Med. NY, P.C. v Lancer Ins. Co., 37 Misc 3d 136, 2012 NY Slip Op 52178 ).”
Lack of coverage
Free Consultation · No Fee Unless We Win
Does this apply to your situation?
Every case is different. Get a free, confidential case review from an experienced attorney who can tell you exactly where you stand.
(2) “To the extent defendant seeks summary judgment dismissing these claims on the ground of lack of coverage, a defense which is not subject to preclusion (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 ), defendant’s evidence was insufficient to establish, as a matter of law, that the assignor’s alleged injuries did not arise from an insured incident so as to warrant the dismissal of the complaint (see Central Gen. Hosp., 90 NY2d at 199; Infinity Health Prods., Ltd. v American Tr. Ins. Co., 30 Misc 3d 137, 2011 NY Slip Op 50195 ).”
(Infinity involved an SIU affidavit relying in large part on an inadmissible police report)
Related Articles
- Fee schedule defense requirements and competent evidence standards
- Competent evidence standards for fee schedule defenses
- Understanding medical billing and down-coding in no-fault claims
- How hearsay evidence affects civil court no-fault insurance decisions
- New York No-Fault Insurance Law
Legal Update (February 2026): The fee schedule provisions and reimbursement rates discussed in this 2017 post may have been substantially modified through regulatory amendments and updated fee schedules implemented since publication. Additionally, procedural requirements for fee schedule denials and coverage defenses may have evolved through subsequent regulatory changes and case law developments. Practitioners should verify current fee schedule provisions and denial requirements under the most recent regulations.
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
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
152 published articles in Fee Schedule
Keep Reading
More Fee Schedule Analysis
Acupuncture Reimbursements and Insurance Legalities Explained
Explore the Forrest Chen v. GEICO case and its impact on acupuncture insurance reimbursements in NY. Key insights for providers and patients.
Dec 11, 2024
Simple addition is insufficient
Jodi Jacobs's 2021 mixed appeal: four claims dismissed, one fee balance unresolved, and why the schedule alone did not prove correct code use.
May 22, 2021
CPT Code 97026
New Age v 21st Century: why the insurer failed to win summary judgment on CPT 97026, without establishing the provider's right to payment.
May 13, 2016
It looks like someone did not include the fee schedule as an exhibit in their acupuncture motion
Insurance companies must properly submit fee schedules as evidence when denying acupuncture claims, or risk having their payment denials overturned by courts.
Apr 1, 2013
Uncertified police report is inadmissible
New York courts remain inconsistent on admissibility of uncertified police reports, with some accepting them under CPLR 4518(a) while others reject them as inadmissible hearsay.
Apr 21, 2010
The By Report paradigm
Pavlova's by-report documentation ruling: why Allstate's motion failed, why the provider also lacked judgment, and limits of the repricing commentary.
Nov 25, 2018Was this article helpful?
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 fee schedule 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.
