OGC Op. No. 04-03-10
The Office of General Counsel issued the following opinion on March 12, 2004, representing the position of the New York State Insurance Department.
Re: Medical Specialty No-Fault IMEs
When a No-Fault eligible injured person is being treated by a chiropractor and the persons insurer has requested a medical examination ("IME") of that person in order to evaluate the medical necessity of the chiropractic services performed, must the medical examination be performed by a chiropractor, or may it be performed by a medical doctor?
An insurers medical examination of an eligible injured person to evaluate the medical necessity of health services provided by a chiropractor may be performed by a medical doctor, and need not be performed by a licensed chiropractor.
A chiropractor provided chiropractic services to a No-Fault eligible insured and billed the persons insurer for performing such services. The insurer subsequently requested that the person submit to an IME, which was performed by a PMR (pain management rehabilitation) doctor. As a result of the IME findings, the insurer issued a denial for reimbursement of the services performed.
Under the Departments No-Fault Regulation 68, N.Y. Comp. Codes R. & Regs. tit. 11 § 65.11(d), which contains the prescribed No-Fault endorsement, an insurer is entitled to require a medical examination of the eligible injured person in order to verify proof of claim. There is no requirement in the regulation that a claim denial must be based upon a medical examination conducted by a health provider of the same specialty area as the treating provider. An arbitrator or court may consider the qualifications of the health provider performing the IME in determining the validity of a claim denial.
For further information you may contact Supervising Attorney Lawrence M. Fuchsberg at the New York City Office.