Derek Bell DC v. LM Property & Casualty Insurance Company (8/16/2010)
Read Full Decision (.pdf) »
The peer reviewer argued that the treatment in this case was not necessary because it was palliative in nature and not curative. The arbitrator noted that recent decisions have moved away from bright line assessments and have held simply that treatment is no longer necessary where it is not improving or otherwise benefiting a claimant. Treatment that is not providing any “curative” or “palliative” benefits may no longer be necessary. But, palliative care, though not necessarily affecting a cure can fit within this holding if defined as treatment that lessens the severity of pain and suffering and improves the quality of the patient’s life. In such instances, palliative care can be necessary and reimbursable. The issue then becomes: what degree of palliative relief justifies reimbursement under the No-Fault regulations. Here, the patient stated that she did receive relief from chiropractic treatment, but by the time of the next weekly visits, the complaints had returned and she was unable to perform her daily routines. The insurance carrier, by focusing on palliative care in general rather than parsing necessity on the basis of the scope and extent of benefit of palliative care, failed to meet the burden of production and persuasion as to lack of medical necessity.

Chiro Care of NY v. Geico Insurance Company (8/4/2010)
If the Respondent asserts that the Applicant failed to submit timely proof of claim, but the Applicant rebuts with date stamped proof of mailing with an accompanying affidavit evidencing timely submission of the bills, Respondent’s denials are deemed untimely AND, respondent’s additional defense of lack of medical necessity is PRECLUDED pursuant to Presbyterian Hospital v. Maryland Casualty Co., 90 NY2d 274 (1997).


Recent Decisions