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What is No-Fault Insurance?

by Halina Radchenko

New York State is a No-Fault state. No-Fault insurance is provided through every automobile policy issued in the state of New York to cover your medical expenses and lost wages that arise as a result of a motor vehicle accident.

Even if you have private health insurance, you must use No-Fault insurance when you are involved in a motor vehicle accident. No-Fault insurance carries a minimum of $50,000 for medical treatment and other expenses.

Every motor vehicle which is insured in the state of New York carries a policy of No-Fault insurance. When you are involved in a motor vehicle accident and require medical treatment, you are covered by the insurance of the motor vehicle you are operating or a passenger in when the accident occurred. If you are a pedestrian or bicyclist you are covered by the insurance of the motor vehicle that hit you.

Who is at fault for the accident does not matter. As long as the injuries arise out of the use or operation of a motor vehicle, you are eligible for No-Fault insurance coverage.

When you are involved in a motor vehicle accident in the state of New York, you should always go to a hospital. Your medical bills will be covered by No-Fault insurance.

No-Fault can also cover a portion of your lost wages if you cannot work for a period of time following the motor vehicle accident. No Fault will pay 80% of your monthly wages, up to $2,000 per month.

Is there a time limit to apply for No-Fault?

You must file a No-Fault application within 30 days or a reasonable time thereafter. If you are able to file your No-Fault application within 30 days, you should do so. There is a limited set of circumstances where you will be allowed to file the application after the expiration of the 30-day period.

Exceptions to the 30-day rule include being incapacitated in the hospital for 30 days, or if you were unable to obtain the insurance information for 30 days, despite trying to do so.

You must be very careful as insurance carriers rarely accept a No-Fault application after the expiration of the 30-day period. As a rule of thumb, you must file within the 30 days following the accident.

Where do I find the information I need?

Insurance information can be found on the Police Accident Report. New York State Police Crash Reports have a section for each vehicle involved in the motor vehicle accident. There is a small box marked ins. code where the officer will indicate a code to identify the insurance carrier. These codes can be found on this website.

No-Fault Insurance

You will need to complete the No-Fault application and mail it back to the insurance company. You can find the application here. Always keep a copy of your completed No-Fault application for your records.

There are many pitfalls in filling out the application, so consulting an attorney can be helpful. If you have been involved in a motor vehicle accident, we recommend contacting an attorney to ask for help in filling out this application.

How will the No-Fault Insurance Company Receive my Medical Bills?

When you visit a medical professional or receive a medical bill from a medical professional for treatment in connection with a motor vehicle accident, it is important that you take the following steps:

  1. When you visit a medical office, you must provide them with the name of the insurance carrier and the claim number associated with the claim. The medical professional will ask you to sign an assignment of benefits form. Once you sign the assignment of benefits form, the medical provider is responsible for submitting medical bills in connection with your treatment. Even if you don’t have all the information, always give the medical office what you have.
  2. If you receive a medical bill, you should call the medical provider immediately and tell them that this treatment was in connection with a motor vehicle accident. Simply stated, tell them “This is a No-Fault claim.” You should provide them with the insurance information, claim number, and insurance adjuster information (if you know it). You should also call the insurance company and tell them that you received a bill. You should mail, email, or fax the medical bill to the insurance carrier to ensure that they receive it in a timely manner. Keep a record of all bills you submit.

If you retain an attorney in connection with your accident, the attorney will help you to ensure that your bills are submitted and paid in a timely manner.

How do I Submit a Claim for Lost Wages?

To submit a claim for lost wages you will need to make sure that the claim is submitted no later than 90 days after the date you missed time from work. This is in addition to your No-Fault application.

You will need to submit three separate forms to the insurance carrier to collect lost wages. The first form is a DB 450 which is filled out by the injured party. That form can be found here.

Your employer will be required to submit a NF-6 form to verify your wages and employment as well as the time which was missed from work. The NF-6 form can be found here. Many times, the insurance carrier will require that the NF-6 form is mailed directly from your employer to the insurance carrier.

If you are self-employed, you will instead submit an NF-7 form, found here.

Finally, your medical provider must submit a disability note verifying that a medical professional has stated that you are not able to complete your work-related duties. The disability note must be updated every 30 days in order to continue receiving lost wage payments through No-Fault. Because of this, it is critical to talk to your doctor about your ability or inability to return to work.

What is an Independent Medical Examination (IME)?

When you are receiving medical benefits through No-Fault insurance you will be required to attend periodic medical examinations with a medical provider designated by the insurance carrier. The role of the medical examination is to ensure that you require ongoing medical treatment.

Insurance companies can use these exams to limit your benefits. If you fail to attend the independent medical examination (IME) and fail to reschedule it, the insurance carrier will be able to terminate your benefits and deny payment for any medical bills from the inception of the claim. It is imperative that you attend these examinations or reschedule them in a timely manner.

At the IME, the medical professional will determine whether or not you require further treatment. If there is a determination that you do not need further treatment you will receive a form, known as a “Denial of Benefits.” The “Denial of Benefits” will provide you with a copy of the medical examination and a date that your benefits will be terminated. The cutoff date is the last date for which the carrier will pay for medical treatment and lost wages. A “Denial of Benefits” may apply to a certain benefit or type of treatment but may not apply to other benefits.

If you receive a denial, you should discuss this with your attorney and your medical provider. There are legal options your attorney and medical provider have to force the insurance company to continue payment.

What is an Examination Under Oath (EUO)?

When you are using No-Fault insurance to pay for medical treatment and lost wages, the insurance carrier has a right to conduct an examination under oath to investigate the claim (EUO). The EUO is a question-and-answer session between an attorney who represents the carrier and the claimant. The insurance carrier can ask you a wide array of questions. The topics can include how the accident happened, the mechanism of injury, the specific medical treatment you received, and many other topics.

If you do not attend this examination your benefits will be terminated and no bills will be paid. Refusal to respond to certain questions at this examination can also lead to a denial of benefits.

If you have a lawsuit pending in connection with the motor vehicle accident, defendants have a right to see the testimony (or transcript) from your EUO. Your responses at the EUO are very important and can affect your lawsuit. It is imperative to be represented by an attorney at this proceeding.

Can I use my Private Health Insurance after a Motor Vehicle Accident?

If you have exhausted the No-Fault insurance policy, meaning you have spent all of the money under the policy, your private health insurance policy must provide payment for ongoing medical treatment.

In New York State, the minimum amount of a no-fault policy of insurance is fifty thousand ($50,000) dollars. In some circumstances, auto policies carry more than $50,000 in No-Fault coverage.

Once you have used the entire amount of the policy you will receive a denial which states that the no-fault policy limits have been exhausted. When that occurs, you should give your medical provider a copy of your private insurance information and direct them to bill your private carrier. The private carrier will require a copy of the denial of benefits based on exhaustion. They will then continue paying the bills upon receipt of the denial.

When you receive No-Fault benefits, the automobile insurance company has the right to conduct independent medical exams to determine if benefits are necessary. If the independent doctor (which is not really independent) determines benefits are not necessary, your coverage can be cut off.

You can also use private health insurance when the doctor conducting an independent medical examination determines that you do not require further medical treatment and no-fault refuses to pay for further treatment. Always listen to the advice of your treating physician. If your physician prescribes medical treatment after the IME doctor denies it, you should continue with your medical treatment.

You must be careful when using your private health insurance for the payment of medical treatment related to a motor vehicle accident. You may be responsible to reimburse your private health insurance carrier for any payments made in connection with your medical treatment if you collect money from the at fault party. You should consult with an attorney to make sure you do not owe any types of repayment if you have used your private health insurance. Contact Hach & Rose, LLP at (212) 779-0057 for a free consultation.

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