NY No-Fault Benefits: Medical Treatment

When you are injured in a car accident in New York, having No-Fault insurance can help cover your medical bills up to a certain amount.

New York is one of a dozen No-Fault states that has in place “personal injury protection,” (PIP coverage) in the form of No-Fault insurance as part of everyone’s regular automobile insurance coverage.

When you are injured in a car accident in New York, having No-Fault insurance means that you will be able to cover the cost of your medical bills up to $50,000 per injured person.

For a free legal consultation, call 516-451-7900

What Happens If My Medical Expenses Exceed the PIP Limit?

If you have been seriously injured, your expenses can easily exceed the $50,000 coverage limits. When your damages exceed the limits of your personal injury protection coverage, you can seek compensation in a personal injury lawsuit. An experienced Long Island car accident lawyer can seek maximum compensation that also includes pain and suffering, disfigurement and scarring, loss of enjoyment of life, and more for severe injuries.

Under New York law, you have a right to sue another party involved in the car accident for pain and suffering if you sustained a “serious injury” as defined in the Insurance Law.

What Constitutes “Serious Injury” in New York?

Under New York insurance law, a “serious injury,” is a personal injury that results in:

  • Death, dismemberment, or significant disfigurement
  • Fracture/broken bone
  • The loss of a fetus
  • The permanent loss or limitation of use of a body organ, member, function, or system
  • A significant limitation of use of a body function or system
  • Inability to perform your usual and customary activities for at least 90 out of the first 180 days following the car accident

Types of Medical Care Covered By NY No-Fault Insurance

NY No-Fault insurance will cover the costs of reasonable and necessary rehabilitation and medical expenses up to $50,000 per person injured in a car accident and include:

  • Medical costs and surgical treatments related to your injury;
  • Physical therapy and rehabilitation;
  • Ambulance services;
  • Diagnostic tests such as x-rays, CT scans, and MRIs;
  • Medical equipment and supplies;
  • Prescription drugs.

Who Pays For No-Fault Damages?

In an auto accident in New York, your own auto insurance personal injury protection covers medical expenses, financial losses, lost wages, and other accident-related expenses for an injured driver and passengers in the car. Usually outlined as personal injury protection or medical benefits, this coverage is subject to the limits set by your insurer. No-Fault insurance is the primary payer, which means it will cover your accident-related expenses before your health insurance. Pedestrians and bicyclists receive coverage from the vehicle that hit them, while passengers are covered by the vehicle they were riding in.

Who Is Covered By a No-Fault Insurance Policy?

Who Is Covered by a No-Fault Insurance Policy?

The benefits from a No-Fault policy apply to anyone riding in an insured vehicle, as well as pedestrians or cyclists who may have been hit in a motor vehicle accident.

Who Is Not Covered Under NY PIP?

In the state of New York, motorcyclists and their passengers are not covered under a standard No-Fault vehicle policy. Pedestrians and cyclists are still covered by PIP if they were struck by a motorcycle.

Uninsured Vehicles

Also, if you are riding in a car that’s uninsured, you won’t be covered and will have to apply for coverage through either your own auto policy, the policy of a family member residing in the same household who held an active auto policy at the time of the accident, or the Motor Vehicle Accident Indemnification Corporation (MVAIC). Injured pedestrians or cyclists can also make a claim through their personal No-Fault coverage or via MVAIC if they were struck by an uninsured vehicle.

How Does No-Fault Insurance Medical Payments Coverage Work?

You will need to submit your claim to your own insurance company for lost wages and other expenses related to the accident. Your physicians will directly bill your No-Fault carrier and PIP will pay before your health insurance. Your insurance company will then cover certain financial losses resulting from the auto accident, regardless of who caused it, up to the coverage limit and based on the nature of the claims.

Processing Timelines for No-Fault Benefits

New York Insurance Regulation 68 stipulates that written notice of a No-Fault claim must be submitted within 30 days of the accident, medical bills must be submitted within 45 days, and lost wage claims must be submitted within 90 days. Some exceptions may be made if the eligible injured person submits written proof providing clear and reasonable justification for the failure to comply with the specified time limitation.

Does No-Fault Insurance Cover Visits to My Own Doctor?

Not all physicians or medical offices accept No-Fault insurance. It’s a good idea to consult your doctor’s office to find out if they accept No-Fault coverage when seeking treatment after a car accident.

Independent Medical Examination in a No-Fault Claim

After you’ve begun getting care from your physician, the No-Fault insurance company will start the process of verifying your injuries. They may send you to one of their own doctors for an Independent Medical Examination (IME).

Consequences of Failing to Attend an IME

It is crucial to attend the Independent Medical Examination if it is scheduled. Failure to attend two times may result in the No-Fault insurance company retroactively denying benefits. In simpler terms, they may deny benefits from the date of your initial injury and seek reimbursement for any treatment, wages, or expenses that have already been paid. It is important to understand the potential consequences and ensure compliance with the IME requirements.

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Can No-Fault Insurance Be Denied?

After your No-Fault car insurance company has received the medical bills, they may audit your claim for legitimacy and require you to attend an IME. If your insurance company believes that a service was unnecessary or not related to the car crash, they may deny your claim.

If you still need medical treatment for your car accident injury after your No-Fault insurer will no longer pay your doctors’ bills, you may seek coverage via your health insurance company.

Pursuing Arbitration

If your claim for accident-related expenses or professional health services has been denied, you have the option to pursue arbitration. This approach offers a means to resolve treatment or wage disputes involving the patient, the doctor, and the insurance companies.

Arbitration can be initiated with the American Arbitration Association (AAA) online via the AAA New York Insurance ADR Center.

What is the AAA?

The AAA is a non-profit organization dedicated to resolving disputes through arbitration, mediation, conciliation, and other voluntary methods. For over 30 years, the American Arbitration Association has administered the No-Fault Dispute Program in New York on behalf of the New York State Department of Financial Services. This program efficiently resolves disputes related to No-Fault car insurance claims, benefiting consumers, healthcare providers, and insurance carriers in New York.

Filed Under: Car Accidents

For a free legal consultation, call 516-451-7900

Practice Areas

Our Long Island Injury Lawyers Have Experience In

Truck Accidents
Accidents on the highways can be lethal events
Bicycle Accidents
Riding a bicycle should not be unsafe
Car Accidents
If you have been seriously injured, call our firm
Motorcycle Accidents
Motorcycle accidents often result in serious injury
Medical Malpractice
Medical mistakes can cause death ruin lives
Wrongful Death
When negligence results in the death of a loved me
Premises Liability
When hurt in a location, someone has to take responsibility
Brain Injury
Brain injuries can have long term severe effects
Dog Bites
Dog bites can cause serious injury


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