NY No-Fault Insurance: Serious Injury Threshold vs Medical Necessity

NY No-Fault Insurance: When Serious Injury Threshold Meets Medical Necessity

The case of Ampofo v Key, 2019 NY Slip Op 00559 (1st Dept. 2019), demonstrates the complex interplay between New York’s serious injury threshold under Insurance Law § 5102(d) and medical necessity requirements under Insurance Law § 5106. This First Department decision illustrates how no-fault peer reviews can effectively undermine personal injury claims, even when plaintiffs have documentation of their injuries.

The court noted: “Defendants established prima facie that plaintiff’s claimed right ankle and foot sprains were not serious injuries within the meaning of Insurance Law § 5102(d) through affirmed reports by their orthopedist, who documented normal range of motion. They also submitted an affirmed report by an orthopedic surgeon who performed a no-fault peer review, which noted that plaintiff’s MRI reports showed osteoarthritis and other conditions, and opined that the right ankle arthroscopy performed four months after the collision was not medically necessary or causally related to the accident.“

This decision highlights the powerful role that no-fault peer reviews can play in both undermining serious injury claims and challenging the medical necessity of treatment for car accident victims in Nassau County, Suffolk County, and New York City.

Understanding New York’s No-Fault Insurance System

New York’s no-fault insurance system was designed to provide prompt payment of medical expenses and lost wages regardless of fault, while limiting lawsuits for pain and suffering damages. However, the system includes two critical limitations that often work together to protect insurance companies from liability.

Insurance Law § 5102(d): The Serious Injury Threshold

Under Insurance Law § 5102(d), accident victims can only pursue lawsuits for pain and suffering damages if they can demonstrate a “serious injury,” defined as:

• Death
• Dismemberment
• Significant disfigurement
• Fracture
• Loss of a fetus
• Permanent loss of use of a body organ, member, function or system
• Permanent consequential limitation of use of a body organ or member
• Significant limitation of use of a body function or system
• Medically determined injury or impairment of a non-permanent nature that prevents the injured person from performing substantially all of the material acts which constitute such person’s usual and customary daily activities for not less than 90 days during the 180 days immediately following the occurrence of the injury or impairment

Insurance Law § 5106: Medical Necessity Requirements

Separately, Insurance Law § 5106 requires that all treatment covered by no-fault insurance be “medically necessary.” This means treatment must be:

• Appropriate for the diagnosis and treatment of the covered injury
• In accordance with generally accepted medical practice
• Not experimental or investigational
• The most appropriate supply or level of service considering cost and effectiveness

The Strategic Use of No-Fault Peer Reviews

The Ampofo case demonstrates how insurance companies strategically use no-fault peer reviews to attack both the serious injury threshold and medical necessity requirements simultaneously. This dual approach can be devastatingly effective for defendants.

How Peer Reviews Undermine Serious Injury Claims

No-fault peer reviews conducted by insurance-retained doctors serve multiple purposes in Long Island and New York City personal injury cases:

• Range of Motion Testing: Peer reviewers often document normal or near-normal range of motion, which can undermine claims of significant or permanent limitation of use
• Pre-existing Condition Arguments: Reviews frequently identify pre-existing conditions like arthritis or degenerative changes to argue that current symptoms are not accident-related
• Causation Challenges: Peer reviewers may opine that treatment or symptoms are unrelated to the subject accident
• Credibility Attacks: Reviews can question the legitimacy of patient complaints and the necessity of treatment

Medical Necessity Determinations

In Ampofo, the peer reviewer specifically opined that the plaintiff’s ankle arthroscopy was “not medically necessary or causally related to the accident.” This type of determination serves dual purposes:

• It can be used to deny no-fault coverage for the treatment
• It supports arguments that the injury was not serious enough to warrant such intervention
• It suggests that symptoms requiring treatment were pre-existing rather than accident-related

The Problem with Peer Review Standards

The Ampofo case highlights a concerning trend in New York appellate courts’ acceptance of peer review opinions that might not meet the standards typically required in no-fault arbitration proceedings. The case commentary notes that “the medical rationale would not suffice for most arbitrators, but alas the Appellate Division found it persuasive.”

Different Standards for Different Proceedings

This discrepancy creates several problems:

• Inconsistent outcomes: The same peer review that fails in no-fault arbitration may succeed in threshold motions
• Lowered standards: Courts may accept less rigorous medical analysis in the summary judgment context
• Strategic forum shopping: Insurance companies can choose the most favorable venue for their medical arguments
• Unfair advantages: Defendants benefit from more lenient standards in civil court than they would face in no-fault proceedings

Common Defenses Using the 5106/5102(d) Intersection

Insurance companies and their attorneys have developed sophisticated strategies that exploit the intersection of these two statutory provisions.

The “Pre-Existing Condition” Strategy

Peer reviewers often identify pre-existing conditions and argue that:

• Current symptoms are attributable to pre-existing conditions rather than the accident
• Treatment was necessitated by pre-existing conditions, not accident-related injuries
• Any limitations of use existed before the accident
• The accident was merely a temporary aggravation of pre-existing conditions

The “Normal Range of Motion” Defense

As seen in Ampofo, demonstrating normal range of motion during an examination can be powerful evidence against serious injury claims, particularly for:

• Significant limitation of use claims under § 5102(d)
• Permanent consequential limitation claims
• 90/180 day limitation claims

The “Unnecessary Treatment” Argument

By arguing that treatment was not medically necessary, peer reviewers can undermine both no-fault coverage and serious injury claims by suggesting:

• The injury was not severe enough to require extensive treatment
• Treatment was excessive or inappropriate given the actual extent of injury
• The need for treatment was driven by factors other than accident-related injuries

Strategies for Overcoming Peer Review Challenges

Despite the challenges posed by strategic peer reviews, there are ways to effectively counter these defenses in New York no-fault cases.

Challenging Peer Review Methodology

Effective responses to peer reviews should examine:

• Examination procedures: Was the examination comprehensive and appropriate?
• Review of records: Did the reviewer consider all relevant medical documentation?
• Timing issues: Was the examination conducted at an appropriate time relative to the accident and treatment?
• Bias indicators: Does the reviewer have a history of consistently favoring insurance companies?

Strengthening Medical Documentation

To counter peer review challenges, treating physicians should:

• Document range of motion limitations objectively and consistently
• Clearly explain the medical necessity for all recommended treatment
• Address pre-existing conditions and differentiate them from accident-related injuries
• Provide detailed causation analysis connecting treatment to accident-related injuries

Expert Witness Strategy

Retaining qualified medical experts who can counter peer review findings is often essential:

• Board-certified specialists in the relevant medical field
• Experts familiar with no-fault standards and requirements
• Physicians who can provide detailed rebuttal to peer review conclusions
• Experts who can explain the medical necessity of treatment

Frequently Asked Questions About No-Fault Insurance and Serious Injury Thresholds

What is a no-fault peer review and why does it matter?

A no-fault peer review is an independent medical examination conducted by a doctor retained by the insurance company to evaluate whether treatment is medically necessary and related to the accident. As the Ampofo case shows, these reviews can be used not only to deny no-fault benefits but also to undermine serious injury claims in personal injury lawsuits.

Can I be forced to attend a peer review examination?

Yes, if you’re receiving no-fault benefits, you can be required to attend independent medical examinations as a condition of continued coverage. However, there are limits on the frequency and scope of these examinations, and you have rights regarding the examination process.

What happens if a peer reviewer says my treatment wasn’t medically necessary?

If a peer reviewer determines that treatment was not medically necessary, the insurance company may deny coverage for that treatment. You can challenge this determination through the no-fault arbitration process. Additionally, such findings may be used against you in any personal injury lawsuit.

How do pre-existing conditions affect my no-fault and personal injury claims?

Pre-existing conditions don’t automatically disqualify you from benefits or damage awards, but they can complicate your case. The key is proving that the accident aggravated or worsened your pre-existing condition, or that new injuries occurred despite pre-existing conditions.

What is the difference between the serious injury threshold and medical necessity?

The serious injury threshold (§ 5102(d)) determines whether you can sue for pain and suffering damages. Medical necessity (§ 5106) determines whether no-fault insurance will pay for your treatment. These are separate standards, but as the Ampofo case shows, they often intersect in litigation strategy.

The Evolution of No-Fault Law

The Ampofo decision reflects broader trends in New York no-fault law that have generally favored insurance companies over injured parties.

Increasingly Stringent Standards

New York courts have progressively raised the bar for meeting the serious injury threshold:

• More rigorous requirements for objective proof of limitations
• Greater scrutiny of medical documentation and expert testimony
• Increased acceptance of defense medical examinations and peer reviews
• Stricter causation requirements linking injuries to accidents

The Insurance Industry’s Advantage

Several factors have shifted the balance in favor of insurance companies:

• Development of sophisticated peer review networks
• Standardization of defense medical examination protocols
• Court acceptance of lower evidentiary standards for defense medical opinions
• Strategic use of multiple statutory provisions to attack claims

Protecting Your Rights in No-Fault Cases

Given the challenges highlighted by the Ampofo case, accident victims need experienced legal representation to navigate the complex intersection of no-fault insurance law and personal injury litigation.

Early Case Development

Success in no-fault cases often depends on early attention to key issues:

• Immediate medical attention: Seek prompt, comprehensive medical evaluation after accidents
• Documentation: Ensure all symptoms and limitations are properly documented
• Treatment compliance: Follow all recommended treatment protocols
• Expert selection: Work with medical providers familiar with no-fault requirements

Responding to Insurance Company Tactics

Understanding insurance company strategies helps in developing effective responses:

• Prepare thoroughly for independent medical examinations
• Challenge inappropriate peer review findings
• Develop strong medical expert testimony
• Address pre-existing condition arguments proactively

The Ampofo case serves as a reminder that New York’s no-fault system, while designed to provide prompt compensation to accident victims, has evolved into a complex legal framework that often favors insurance companies. The strategic use of peer reviews to attack both medical necessity and serious injury thresholds demonstrates the sophisticated approaches insurers use to minimize their liability.

For accident victims, understanding these dynamics is crucial for protecting their rights and maximizing their recovery. The intersection of Insurance Law §§ 5106 and 5102(d) creates challenges that require experienced legal guidance to navigate successfully.

If you’ve been injured in a car accident in Nassau County, Suffolk County, or New York City and are dealing with no-fault insurance issues or serious injury threshold challenges, call 516-750-0595 for a free consultation with experienced attorneys who understand the complex interplay between no-fault insurance law and personal injury litigation.

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Legal Update (February 2026): Since this post’s publication in 2019, New York’s no-fault insurance regulations under Insurance Law §§ 5102 and 5106 may have been subject to regulatory amendments, particularly regarding peer review procedures, medical necessity standards, and serious injury threshold determinations. Additionally, appellate decisions interpreting the interplay between serious injury thresholds and medical necessity requirements may have evolved. Practitioners should verify current regulatory provisions and recent case law developments when analyzing similar no-fault insurance disputes.