Key Takeaway
Court ruling in Laga v GEICO shows insurers must provide precise proof when applying Ground Rule 11 reductions to no-fault medical bills under New York's fee schedule.
GEICO’s Fee Schedule Defense Falls Short in Appeals Court
New York’s no-fault insurance system relies on detailed fee schedules to determine appropriate reimbursement rates for medical providers. When insurers attempt to reduce payments using Ground Rule 11 calculations, they must present precise documentation to justify their reductions. A recent Appellate Term decision demonstrates just how exacting courts can be when reviewing these fee schedule disputes.
In cases involving New York No-Fault Insurance Law, insurance companies frequently invoke Ground Rule 11 to reduce medical bill reimbursements. However, as this case illustrates, general claims without proper supporting documentation rarely survive judicial scrutiny.
Jason Tenenbaum’s Analysis:
Laga v GEICO Ins. Co., 2017 NY Slip Op 51713(U)(App. Term 2d Dept. 2017)
“Defendant failed to demonstrate that it had used the correct conversion factor in calculating the reimbursement rate, or that it had appropriately applied Ground Rule 11. Consequently, the branches of defendant’s cross motion seeking summary judgment dismissing those causes of action should have been denied. ”
From what I am observing, this Court appears to be very exacting on the proof necessary to establish GR 11 reductions. Outside the affidavit of a certified fee coder, I have not seen anyone have much success with these cases on motion with claims affidavits.
Key Takeaway
Insurance companies must provide detailed, technically accurate documentation when applying Ground Rule 11 reductions to medical bills. Courts require more than general claims affidavits - typically demanding certified fee coder affidavits to establish proper calculation methods and conversion factors in fee schedule disputes.
Legal Update (February 2026): Since this 2017 post, New York’s no-fault fee schedules and Ground Rule 11 calculation requirements may have been subject to regulatory amendments or updated Department of Financial Services guidance. Practitioners should verify current fee schedule provisions, conversion factors, and documentation standards, as reimbursement methodologies and evidentiary requirements for Ground Rule 11 reductions may have evolved.
