Wachtel v. Metropolitan Life Ins. Co

In Wachtel v. Metropolitan Life Ins. Co., 141 Misc.2d 665 [Dist Ct Nassau Co 1988], rev'd 146 Misc.2d 670 [App Term 2d Dept 1990], the policy was described as excluding coverage for services or supplies that were not "medically necessary" in terms of "generally accepted medical standards as determined by" the insurer; the coverage language is not quoted or described in the opinion. The trial court held that "defendant having failed to provide a clear, specific, restrictive definition to cover the instant situation has the burden of proving plaintiff's claim is not medically necessary." (141 Misc.2d at 669-70.) Appellate Term reversed, finding that "plaintiff established a need" and that defendant "satisfied plaintiff's wife's medical necessity." (146 Misc.2d at 671.)