No-Fault Arbitration FAQs

New York no-fault law mandates that every person injured in a motor vehicle accident receive payment for medical costs, lost earnings and other reasonable expenses. This “personal injury protection” (or PIP) is informally known as “no-fault” because the insurance company is required to provide coverage regardless of who was at fault for the accident. Accident injury victims are eligible to receive no-fault benefits if:

1. They were injured in an automobile accident;
2. They were a pedestrian, bicyclist or snowmobile rider struck by an automobile, motorcycle or ATV; or
3. They were hurt during the use, operation or maintenance of a motor vehicle.

The minimum amount of no-fault benefits available to individuals injured in New York motor vehicle accidents is $50,000 for medical expenses, lost earnings and other reasonable expenses. Any individual can purchase APIP (Additional Personal Injury Protection) to increase the no-fault coverage by another $50,000.

Any individual can purchase OBEL (Optional Basic Economic Loss) coverage of up to $25,000 that extends no-fault coverage beyond the minimum $50,000, for a total of $75,000. Through OBEL the injured individual gets to decide which expenses are covered. For example, an injured party can choose to have the additional $25,000 coverage go towards lost wages. Note that OBEL coverage can only be utilized after the injured person has exhausted the initial $50,000 of basic economic loss coverage.

Before treating an injured individual, healthcare providers that accept no-fault insurance as a form of payment should ensure the injured individual provided “notice of claim” to the appropriate insurance company. The person would have provided the notice by filing one of these documents within 30 days after the accident:

1. an NF-2 form;
2. an NF-5 form; or
3. a Department of Motor Vehicles Accident Report 104 (MV 104) indicating injury.

Generally, a physician who accepts a no-fault assignment of benefits from a no-fault patient may not pursue the patient directly for payment. The form for no-fault assignment of benefits is considered a legal contract. Under that contract, the physician assumes the legal rights to no-fault benefits held by the injured party.

The insurance company can successfully deny the claim for a few reasons, including the lack of insurance coverage because of fraud by the patient, or a policy violation, such as the patient’s failure to appear at independent medical evaluations (IMEs). In those instances, payment could be sought from the patient. The physician can also pursue payments from the patient when payments from the no-fault policy are exhausted.

The AOB form should not be modified. Added language that would attempt to make the patient responsible to pay for medical services will be given no legal effect. For example, it is prohibited to include language in the AOB stating “in the event that the no-fault carrier fails or refuses to pay for the services provided then I, the patient, agree that I will be responsible for the value of the services rendered by said Doctor.”

A medical lien is a claim for repayment that is placed against an accident victim’s personal injury case. Essentially, a medical lien gives a medical provider the right to be repaid for its services from any settlement, judgment or verdict awarded in a personal injury lawsuit to the accident victim. The lien is created by a form authorizing the medical provider to place a lien in the event the insurance company denies the provider’s no-fault claims for the patient. The denial may be due to:

• Lack of coverage for reasons such as fraud or material misrepresentation;
• A policy violation, such as a failure to appear for two IMEs; or
• The exhaustion of the policy’s benefits.

Yes, a medical provider may receive payment for no-fault claims provided to injured parties who violated the insurance policy by failing to appear for two IMEs or two EUOs. An insurance carrier must meet numerous legal requirements to successfully deny a no-fault claim based on the injured person’s failures to appear for IMEs or EUOs.

The breach of policy relieves the insurer of the obligation to provide coverage for all future claims for the injured party’s health services arising from the same accident. Pending claims submitted by the carrier may also be denied based on the policy breach.

However, if the pending claim is for treatment provided prior to the policy breach, an arbitrator or court of law may find the denial ineffective. An insurer’s successful denial of claims due to policy violation does not create a right of recovery for the insurer for benefits previously paid.

Providers can sometimes receive payment for no-fault claims even if the injured person’s policy has already been exhausted. In order to determine whether you may be able to receive payment for those kinds of claims, contact us so we can evaluate the validity of the insurer’s denial.

All providers and hospitals covered by the Health Insurance Portability and Accountability Act (HIPAA) are now required to use the new International Classification of Diseases, 10th Edition (ICD-10), which is a diagnosis and procedure coding system. Current Procedural Terminology (CPT) codes, which are usually used when claims for health care services are reported to workers’ compensation and no-fault insurers, are not affected by ICD-10. The New York Workers’ Compensation Board made the change to ICD-10 in order to be consistent with both Medicare and Medicaid, and to avoid the costs of supporting two diagnostic coding systems.

Yes. Additional personal injury protection benefits that are both mandatory and overdue bear interest at a rate of two percent (2%) per month, calculated on a pro-rata basis using a 30-day month. An insurer must deny or fail to pay a claim within the mandatory 30-day period. If the insurer does not act in one of those two ways, the claim begins to accrue interest at that point, as it has become overdue. If arbitration or a lawsuit is not commenced within 30 days of the receipt of the denial of claim form for payment of benefits, the accrual of interest is paused until an action is begun.

The Health Insurance Portability and Accountability Act (HIPAA) provides data privacy and safeguards for medical information. HIPAA applies to all healthcare providers that transmit health information in electronic form. The mandate protects individuals’ health information from being used or disclosed by covered entities. Covered entities are any organizations or corporations that directly handle protected health information.

Protected health information under HIPAA includes:

• The patient’s name, address, birth date, and Social Security number.
• An individual’s physical or mental health condition.
• Any care provided to an individual.
• Payment information that identifies the patient or could be used to identify the patient.

If you fail to provide a proper legal answer to the Declaratory Judgment motion, a Default Judgment may be granted against you. It is crucial that you hire a law firm with the experience to provide you with proper legal representation.

Contact the patient/patient’s legal representative or contact the Workers Compensation District office. The New York Workers’ Compensation telephone directory can be found here. Copies of all documentation should also be sent to the NYS Workers’ Compensation Board either via mail to P.O. Box 5205, Binghamton, NY 13902, OR via fax to 1-877-533-0337. Complex legal issues can arise at the intersection of workers’ compensation law and no-fault insurance policies. To learn more about your specific issues, contact The Tadchiev Law Firm, P.C., today.