Key Takeaway
New York court finds conflicting medical opinions create triable issue on physical therapy necessity, despite provider's weak affidavit of merit in no-fault insurance case.
In New York’s no-fault insurance system, disputes over medical necessity frequently arise when insurance carriers challenge the appropriateness of treatments provided to injured patients. These cases often hinge on competing medical opinions, where healthcare providers must demonstrate that their treatments were medically necessary while carriers argue otherwise. The burden of proof and quality of medical evidence can significantly impact the outcome of these disputes.
Medical necessity determinations are particularly important in New York no-fault insurance law because they directly affect whether providers receive reimbursement for their services. Courts must carefully evaluate the medical evidence presented by both sides, including peer review reports, expert affidavits, and treatment records. When medical opinions conflict, courts typically find that genuine issues of material fact exist, preventing summary judgment and requiring a trial to resolve the dispute.
The quality and substance of medical evidence varies significantly from case to case, as demonstrated in various medical necessity reversals where seemingly similar evidence has led to different outcomes.
Jason Tenenbaum’s Analysis:
DRD Med., PC v Global Liberty Ins. Co. of N.Y, 2020 NY Slip Op 50385(U)(App. Term 1st Dept. 2020)
“We agree with Civil Court that the conflicting medical opinions adduced by the parties sufficed to raise a triable issue as to the medical necessity of the physical therapy treatments underlying plaintiff’s claims”
Amazingly, this is no different than cases where the carrier has won except the affidavit of merit in this case has a bunch of verbiage but no substance
Key Takeaway
This case illustrates that even when a provider’s medical evidence lacks substance, conflicting medical opinions between parties can still create triable issues that prevent summary judgment. The court’s decision demonstrates that the mere existence of competing medical viewpoints, regardless of their quality, often compels courts to allow cases to proceed to trial rather than dismissing them outright. This highlights the importance of presenting strong, substantive medical evidence rather than relying on verbose but empty affidavits.
