NY No-Fault Benefits: Medical Treatment

If you were hurt in a car accident, no-fault insurance might just give you the help you need. If you live in a handful of states including New York, you might have filed for no-fault benefits and have some questions. What happens next? What kind of treatment is paid for? Where do you go for medical care? Will I have my medical expenses taken care of without risking my home and my property? And perhaps the biggest question is, what does the law say about who pays for your medical bills?

If you reside in New York State, you’re in luck. New York is one of only about a dozen no-fault states that have in place “personal injury protection,” (PIP coverage) in the form of No-Fault insurance as part of everyone’s regular automobile insurance. No-Fault insurance ensures that you will be able to cover the cost of your medical treatment bills without having to pay out-of-pocket. It also ensures that your doctor is not going to be left without your paying your medical bills after your car accident is a distant memory. No fault also provides wage protection, with coverage up to $2,000.00 per month in lost wages.

In this blog, we cover the following questions:

What Types Of Care Are Provided For Under No-Fault Benefits?

Some of the medical expenses that are included under No-Fault include:

• Hospital
• Medical bills (examples: primary care doctor, orthopedic surgeon)
• Surgical
• Dental
• Ambulance
• X-ray
• Prescriptions
• Prosthetic services
• Psychiatric
• Physical therapy (must have a referral)
• Occupational therapy
• In-patient rehabilitation
• Acupuncture

Who Pays For No-Fault Damages?

When you’re in an auto accident, your own car insurance coverage pays for the medical expenses and other financial losses such as lost wages suffered by anyone covered under your policy. The section of your coverage that takes care of this is usually outlined under the “personal injury protection,” or, “medical benefits,” section of your policy. Your insurance will cover your costs up to the coverage limits outlined by your insurer. If you are a pedestrian or bicyclist, no-fault coverage will be provided by the vehicle that struck you. Passengers receive no-fault coverage from the vehicle in which they were riding.

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 by the driver of a car.

Who Is Not Protected?

In the state of New York, motorcyclists and their passengers are typically not covered under a standard No-Fault vehicle policy. For those passengers, it’s necessary to obtain alternative insurance coverage.

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 or the Motor Vehicle Accident Indemnification Corporation (MVAIC). You can also make a claim through a personal no-fault or MVAIC if a pedestrian or cyclist is struck by an uninsured vehicle.

Is No-Fault Insurance All There Is?

If you wish to pursue additional damages, such as those for “pain and suffering” or additional non-economic losses, you’ll need to move outside of the No-Fault insurance arena and file a third-party claim or lawsuit against the other driver for your losses. In order to do this, your injuries must meet New York’s threshold for what is considered “serious injury.”

What Constitutes “Serious Injury” in New York?

To be considered a “serious injury,” New York State first requires that the bodily injury you suffered be a direct result of your car accident. In addition, New York law stipulates that in order for any bodily injury to be considered, “serious,” you must be able to show:

• Significant disfigurement
• A bone fracture
• Permanent limitation of the use of a body organ or member
• A significant limitation of use of a body function or system, or
• Inability to perform your usual and customary activities for at least 90 out of the first 180 days following the collision.

If your injuries meet these criteria you can now pursue the at-fault driver through a third-party car insurance claim, or a personal injury lawsuit.

Can I Go To My Regular Physician If I’m Involved In A No-Fault Car Accident Claim?

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. Knowing that your physician will take No-Fault insurance will save you from having to search around for one who does.

How Does No-Fault Insurance Work Once I Start Treatment?

Because New York state is one of the “No-Fault” states, the procedure for submitting insurance claims is fairly straightforward. You will be submitting your claim to your own insurance company for lost wages and other accident related expenses. Your physicians will bill your no-fault carrier directly. Your insurance company then covers certain financial losses related to your auto accident, regardless of who caused the accident up to the limit of the coverage and the nature of the claims.

In a no-fault automobile insurance accident claim, you don’t have to prove to the insurance company who was at fault for the car accident.

In contrast, in a third-party accident insurance claim or lawsuit against an at-fault driver, you can recover compensation for pain and suffering, in addition to reimbursement for medical bills and other expenses like lost income. “Pain and suffering” and certain other damages are typically claims that no-fault car insurance doesn’t cover. In order to recover on a liability claim, fault must be established.

It’s in the insurance company’s best interest to deny as many accident payouts as possible. After you’ve begun getting care from your physician, the no-fault insurance company will start the process of verifying your injuries. The no-fault insurance company will attempt to show that you are not injured so they can stop paying for medical costs, lost earnings, and other expenses. Remember, the no-fault auto insurance company must provide up to $50,000 in protection. However, this requirement does not mean they must pay out $50,000 worth of coverage.

In order to “verify” that you are injured, the no-fault insurance company may send you to one of their own doctors for an Independent Medical Examination or IME. You MUST attend the IME if one is scheduled – if you fail to attend two times, the no-fault insurance company may retroactively deny benefits. In other words, they may deny benefits from the date back when you were first injured, and seek to obtain reimbursement for any amounts already paid for treatment, wages or other expenses. Appearing for the appointment is an important first step to ensure that your regular treatments with your own providers are covered. You wouldn’t want your coverage to end simply because you missed your IME.

You Were Denied Coverage – What Now?

What if an insurance company denies any more treatment? More often than not, this is what occurs after the IME or EUO. If you still need medical treatment, which may very well be the case if your accident was serious and left you with substantial injuries, you may continue to receive treatment; however, no-fault will no longer pay your doctors’ bills. If you have a health insurance plan, tell your doctors to start to bill your health insurance instead of no-fault. Your doctors will also ask for insurance information – they want to be paid and if no-fault isn’t paying, they want to know who they should bill.

What about arbitration?

If you were denied coverage, another option is to enter into arbitration. This option provides a way to settle treatment or wage issues between the patient, the doctor, and the insurance companies.

New York is one of the states that allows for arbitration. By going to the American Arbitration Association’s website, you can register your case and begin the arbitration process on your own.

Bear in mind, however, that arbitration can be a complicated and nuanced process. As such, before you file your case, it’s a good idea to search out and contact a qualified attorney to help guide you through this process.

Am I Responsible For Making Payments To My Health Provider If I Lose My Arbitration Case?

If an assignment of benefits is provided to the doctor, then the provider can bring their own claim against the insurance company but cannot pursue payment from the patient directly.

Oftentimes, physicians themselves will arbitrate no-fault denials. Your doctor may continue to provide treatment to you if they plan on arbitrating the denial themselves.

However, if an “Authorization to Pay Benefits” is selected, a patient is still obligated to make payments to their provider, even if they were unable to recover money from a No-Fault insurer.

My No-Fault Insurer Has Denied Payment To My Doctor. Can My Physician’s Office Bill The Insurance Company On My Behalf?

Under the “Authorization” option of the application, the provider has the right to bill the eligible injured patient for their services.

Can The Medical Service Provider Bill The Patient Directly If The No-Fault Is Denied?

In the case where the No-Fault insurer has determined that the patient’s injuries were not related to their accident, the provider would be limited to bill the patient directly for their services. Denial for this reason can also be contested through the arbitration process.

Call a New York Personal Injury Attorney Today

If you have been in an accident and the No-Fault insurance company with whom you have filed a claim is refusing to pay for your medical treatments, make a phone call to one of our personal liability injury attorneys today. We have dealt with cases concerning these types of insurance companies for years. Do not let your injuries go untreated because you cannot pay for medical care. Contact us and let us help you get the coverage that you seek.

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