Key Takeaway
Florida court rules that record keeping violations don't justify denying claims when treatments are medically reasonable and necessary, protecting patient access to care.
Record Keeping Violations Don’t Override Medical Necessity in No-Fault Claims
In the complex world of New York No-Fault Insurance Law, insurance carriers sometimes attempt to deny legitimate claims based on technical violations rather than the medical merits of treatment. A recent Florida appellate decision provides important guidance on when such technicalities should—and shouldn’t—override coverage obligations.
The case highlights a critical distinction between administrative violations and substantive coverage issues. While healthcare providers must maintain proper licensing and record keeping, courts are increasingly recognizing that minor technical violations shouldn’t prevent patients from receiving compensation for medically necessary treatments.
This trend reflects a broader judicial philosophy that prioritizes substance over form in insurance coverage disputes, particularly when the underlying medical care was appropriate and beneficial to the patient.
Jason Tenenbaum’s Analysis:
UNITED AUTOMOBILE INSURANCE COMPANY, vs CENTRAL THERAPY CENTER, INC., A/A/O VANESSA LOPEZ,3D21-950 (Fla 3d DCA 2022)
“We hold that, where an insurer agrees treatments are medically reasonable and necessary, a failure to comply with the record keeping requirements governing the licensing of chiropractors is not a basis
to refuse to compensate the claim. Accordingly, we affirm.”
This reminds of that Bruno, Gerbino cases from 8 years ago where the insurance carrier sought to disclaim benefits based upon am improper referral. The Appellate Division disagreed and found the violation was not a Mallela type of violation that would warrant a disclaimer of coverage.
Key Takeaway
When insurance carriers acknowledge that medical treatments are reasonable and necessary, they cannot subsequently deny claims based solely on administrative record keeping violations. Courts distinguish between technical licensing issues and substantive coverage violations, ensuring that patients receive benefits for appropriate medical care regardless of minor regulatory infractions.
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What is New York's no-fault insurance system?
New York's no-fault insurance system requires all drivers to carry Personal Injury Protection (PIP) coverage. This pays for medical expenses and lost wages regardless of who caused the accident, up to policy limits. However, you can only sue for additional damages if you meet the 'serious injury' threshold.
