THE STATE OF THE LAW

Pain and Surgery Ambulatory v. Geico Insurance Company (8/2/2010)
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Applicant has made a prima facie showing of its entitlement to reimbursement, as a matter of law, by submitting evidentiary proof that the prescribed statutory billing forms, setting forth the fact and the amount of the loss sustained, have been mailed and received and that payment of no-fault benefits is overdue. Once Applicant has established a prima facie case, the burden then shifts to Respondent to establish a lack of medical necessity with respect to the benefits sought. Denial premised on lack of medical necessity must be supported by competent evidence such as an independent medical examination, peer review or other proof which sets forth a factual basis and medical rational for denying the claim. Restated, the evidence must at least show that the services were inconsistent with generally accepted medical/professional practice. A mere statement of opinion is not sufficient to overcome Applicant’s prima face case. Where Respondent has presented sufficient evidence to establish a defense based on a lack of medical necessity, the burden then shifts to the Applicant, which must then present its own evidence of medical necessity and/or rebuttal to Respondent’s peer review.

Village Chiropractic v. Clarendon National Insurance Company (7/22/2010)
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The insurance carrier must obtain expert evidence as to medical necessity. An insurance carrier claim’s adjuster is not legally competent to render medical opinions and should not determine the appropriateness or breadth of medical treatment provided an injured individual. Insurance adjusters should seek the advice, opinion, and assistance of competent medical professionals when evaluating a medical claim. Professional opinions integrating published studies, guidelines and/or procedures, with the facts of the claim are most advantageous. Respondent’s failure to conduct a peer review is inexcusable, meaning Applicant’s bill remains unchallenged.