Key Takeaway
Court rules medical affirmation insufficient when not based on patient examination and fails to rebut defendant's examining physician findings.
In no-fault insurance litigation, the quality and foundation of medical evidence can make or break a case. When healthcare providers challenge insurance denials for medical necessity, courts require robust medical support that meets specific evidentiary standards. The Forest Drugs case demonstrates a critical principle: medical affirmations must be properly grounded in actual patient examinations to carry weight in court proceedings.
This appellate decision highlights the court’s scrutiny of medical evidence in summary judgment motions. When insurers retain examining physicians to evaluate the medical necessity of treatments, providers seeking to challenge these determinations cannot simply submit generic medical opinions. The medical professional offering the counter-opinion must have examined the patient and provide a meaningful rebuttal to the insurer’s examining physician.
This requirement reflects broader principles about the foundation needed for medical evidence in no-fault cases and the importance of comprehensive medical documentation in challenging medical necessity reversals.
Jason Tenenbaum’s Analysis:
Forest Drugs v Global Liberty Ins. Co. of N.Y., 2018 NY Slip Op 51708(U)(App. Term 1st Dept. 2018)
“In opposition, the medical affirmation submitted by plaintiff failed to raise a triable issue since it was not based on an examination of the assignor, nor did it meaningfully rebut the findings of defendant’s examining physician”
Key Takeaway
Healthcare providers must ensure their medical affirmations are based on actual patient examinations when challenging insurance denials. Generic or unfounded medical opinions will not survive summary judgment motions, particularly when the insurance company presents evidence from examining physicians. Proper medical foundation is essential for creating triable issues of fact in no-fault litigation.
