Diagnostic Medical Associates, M.D. v. Guardian Life Insurance Company of America,
No. 98 Civ. 4838 (VM) (S.D.N.Y. Aug. 21, 2001)

The Southern District Court of New York upheld an insurance company's refusal to pay a doctor for medical services the physician had rendered to an enrollee including an x-ray, echocardiogram, EKG, spirometry, venipuncture, and blood tests. The insurance company repeatedly informed the physician that reimbursement for services was conditioned upon receipt of information concerning the diagnosis, prognosis, and expected duration of treatment. It also repeatedly requested copies of the patient's medical record. In response, the doctor forwarded a few pages of illegible, handwritten notes and the results of one blood test. The doctor never provided hard copies of test results for any of the other tests. Rather, he continued to submit claims without providing any meaningful documentation.

Objective and independent peer reviews initiated by the insurer found that the claims were improperly documented and that the need for the services provided was not established by the information provided by the physician. The court found the independent peer reviewers' findings to be dispositive. According to the court, the insurer's written policies clearly required the provider to substantiate his claims for reimbursement, which he consistently failed to do despite repeated opportunities and requests from the insurer.