NY No-Fault Benefits: Denial Of Benefits

You were involved in a motor vehicle accident, and you submitted a No-Fault claim for compensation. Maybe you have a large doctor or hospital bill and it needs to be paid in a timely manner. Your no-fault carrier has the right to send you for an independent medical examination (IME) or conduct an examination under oath (EUO) where they can question you in detail about your treatment. Sometimes, the no-fault carrier’s doctor may determine that additional treatment is not needed, even if your own doctors say it is. Suddenly you find that your claims for coverage are being refused by the insurance carrier. Now you want to know what laws are in place to protect you, and what can you do once this happens?

In this blog we provide answers to the questions:

New York State Is A “No-Fault” State — What Does That Mean?

New York no-fault laws provide basic economic protection for those injured in a motor vehicle collision regardless of who is at fault. A driver or passenger in a vehicle typically receives no-fault coverage from the vehicle in which they were travelling at the time of the collision. Pedestrians or cyclists receive coverage from the vehicle that struck them. Remember, these claims can be filed no matter who’s at fault (no-fault).

In order to sue for compensation for pain and suffering or losses beyond basic economic loss, you must meet the state’s threshold for what is considered to be a serious injury. Some injuries automatically fall into this category. They can include things like:

  • Death
  • Broken bones
  • Dismemberment
  • Scarring or disfigurement
  • Permanent loss of a bodily organ or member
  • Loss of a fetus

Determining the severity of injuries may require help from a personal injury lawyer in order to recover appropriate compensation.

What Happens When You File For No-Fault Benefits In New York State?

If you have any auto insurance in the state of New York, then you have, by law, no-fault coverage as part of your policy.

If you were injured in an accident, first and foremost you should get your injuries taken care of by medical professionals. You generally have 30 days to file a no-fault application following a collision. After you’ve filed for no-fault benefits, the insurance company will usually want to verify your injuries. The insurance company may ask you to appear for an independent medical examination (IME). Here, you’ll probably be examined by a doctor provided by the carrier. They may also require what is called an “examination under oath” (EUO), where you will be questioned about the accident, your treatment or any prior conditions you may have.

If the insurer asks you to appear for an IME or EUO, you will be required to attend. If you fail to attend one of these exams, the insurance company may deny your benefits. But it could get worse than that. If you fail to show up for your exam(s), they may deny your benefits retroactively — meaning, all of the benefits you’ve received so far from the date of the accident may now need to be repaid.

What Happens If I Can’t Make My IME or EUO Appointment?

If you’re scheduled for an IME or EUO, and you can’t, for whatever reason, make your appointment, contact the insurer to see if you can reschedule your appointment.

When you do appear at your IME, it’s possible that the carrier’s physician may decide that your injuries are not as serious as you claim, or that you have achieved maximum medical improvement. If this happens, the insurance company will likely deny coverage for additional medical treatment.

What If My Doctor and The IME Doctor Don’t Agree?

An example would be if your doctor treated you for an injury, and also scheduled you for physical therapy. The no-fault insurance company’s doctor might claim that the treatment of your injuries was sufficient — without continued treatment needed. Or, instead of the prescribed number of visits to your physical therapist, the no-fault insurance doctor might determine that you need fewer treatments. If this happens you may have to pay for the additional visits to your physical therapist out of your own pocket or see if it can be covered by your own personal health insurance.

In the worst-case scenario, the no-fault carrier’s doctor might determine that you need no further treatment. Here, you, your doctor, and your attorney will be notified that your medical benefits have been cut off. If your health insurance isn’t able to cover the additional costs, you will be responsible for any additional medical bills yourself.

Some Common Reasons Your No-Fault Claim Might Be Refused

After filing your claim it might be turned down. Here are some common reasons:

The insurer might claim that you reported your accident or your injuries too late, and for that reason, they won’t pay. In New York, someone who has been injured in an accident must report the accident to the insurance company in writing within 30 days. To do this you’ll need to file a no-fault claim in the form of an NF-2 Form. An individual may simply send the insurance company a written letter, or a copy of the police report. This is not considered written notification by many insurance providers. If you’ve been refused no-fault benefits on this basis, engaging a qualified attorney can help to prove to the insurance company that you still qualify for benefits.

The provider may deny your claim because they state that you reached the limit of your benefits. New York no-fault benefits are typically capped at $50,000. If this is the case, you may be able to claim more benefits through an Additional Personal Injury Protection (APIP) policy. We can evaluate your insurance coverage to determine the benefits you are entitled to under your policy.

What Can I Do If I’m Denied No-Fault Benefits?

If you submit a no-fault claim and the insurer either doesn’t respond within 30 days or outright denies your claim, you may wish to pursue the following options:

  • You can take the insurance company to court. This is a long, costly process that’s very difficult to accomplish successfully without the aid of an attorney.
  • You can file a written complaint with New York State’s Department of Financial Services.
  • You can file for No-Fault arbitration through the American Arbitration Association (AAA).

What Are the Steps for Filing for Arbitration?

Filing for arbitration if you’ve been denied benefits claims for injuries, treatments, or lost wages as the result of an accident can be filed through the American Arbitration Association. There are two ways you can go about this: online or by mail. If you have a pending lawsuit or third-party claim arising out of the accident, speak to your attorney before filing for an arbitration. Your case could be impacted by an arbitration determination.

File for Arbitration Online

To seek arbitration online you can use the New York Insurance ADR Center online service. Their website allows you to complete and submit an Arbitration Request form (AAA Form AR1). Using this website, you’ll be able to submit your form and the site will immediately generate a case number that will provide you an easy way of finding your information in the future.

File for Arbitration by Mail

You can also file for arbitration by mail using a denial of claim form NF-10 issued by the insurer and following the instructions on the form.

Mail completed forms to:
American Arbitration Association
New York Insurance Case Management Center
32 Old Slip, 33rd Floor
New York, NY 10005

What Do I Do If I’m Denied and Haven’t Yet Had a Hearing?

If you have your own health insurance and have received a no-fault benefits denial, you will have to ask your medical provider to directly bill your health insurance carrier.

In a case where you’ve been injured in an accident, the most important thing to do is to make sure you get good medical care. Seek medical treatment immediately, follow through with your doctors’ recommendations, and, if at all possible, continue to follow the recommendations of your own health care providers whether you’ve received a no-fault denial or not.

Getting Help from a New York State Personal Injury Lawyer

If you’ve been injured in a car accident on Long Island, you may find it helpful to get advice from the experienced personal injury attorneys at Rosenberg & Gluck, L.L.P. Our car collision attorneys will take care of all the legal aspects of your case while you concentrate on getting well.

Check out the whole Series:

Filed Under: Car Accidents

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


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