No-Fault, also called Personal Injury Protection (PIP), is designed to pay promptly regardless of who might have been at fault or whether there was any negligence, for economic losses (meaning medical/health expenses, lost earnings, and other reasonable and necessary expenses related to injuries sustained), up to $50,000 per person (“basic No-Fault coverage”), to the driver and all passengers injured in your car as well as any pedestrians injured by your car, because of its use or operation in New York State.
The purpose of No-Fault insurance is to restore individuals hurt in auto accidents to health and productivity as swiftly as possible. Because of New York’s No-Fault law, lawsuits due to auto accidents can be brought only for economic losses that exceed No-Fault benefits and for non-economic damages (such as pain and suffering) only if a “serious injury” (as defined in the Insurance Law) is sustained.
No-Fault is a personal injury coverage and does not pay for auto body repair of your car or damage to any other party’s motor vehicle or real or personal property. No-Fault is also primary to health insurance, which means it pays first in the event injury is due to an auto accident. Under this coverage, your insurer provides you, as well as all relatives living in your household, with protection against economic losses arising from injuries sustained in motor vehicle accidents anywhere within the United States, its territories and possessions, or Canada. It also provides coverage for any passengers injured in accidents in New York State while in your vehicle, as well as any guest passengers who are New York State residents injured in your vehicle anywhere in the United States, its territories and possessions, or Canada, if they are not covered under another auto insurance policy in New York State. All pedestrians injured by motor vehicles in the State are also protected by No-Fault.
Basic No-Fault auto insurance coverage includes:
reasonable and necessary accident related medical and rehabilitation expenses (in accordance with established fee schedules);
80% of lost earnings from work, up to a maximum payment of $2,000 per month for up to three years from the date of the accident;
up to $25 a day, for up to a year from the date of the accident, to reimburse other reasonable and necessary expenses, (e.g., household help, and transportation expenses to/from medical treatment) resulting from the auto accident; and
a $2,000 death benefit (in addition to the $50,000 basic No-Fault limit), payable to the estate of a person eligible for No-Fault benefits but killed in a motor vehicle accident.
However, a person will be ineligible for No-Fault benefits, if:
driving while intoxicated or impaired by use of a drug that contributes to the accident;
intentionally causing his or her own injuries;
riding an all terrain vehicle (ATV) or a motorcycle as operator or passenger (a pedestrian struck by a motorcycle or ATV is covered);
injured while committing a felony;
injured while in a vehicle known to be stolen; or
an owner of an uninsured vehicle.
There are three important steps to follow in order to increase your chances that the insurance company will pay No-Fault benefits in the manner that the No-Fault law was designed:
1. In order to qualify for No-Fault benefits, you must file a No-Fault Application (form NF-2) with the insurance carrier of the car you were in when the car accident took place. If you were a pedestrian, you should send the form to both the insurance carrier of the car that hit you and the insurance carrier of a car that you own (if you own a car). When you speak to your insurance company, ask for the form. They won’t always send it to you automatically because they know of the time contraints.
There are serious time constraints, so, if you are in an accident, it is especially important not to delay filing the No-Fault Application. You have thirty (30) days from the date of the auto accident to file the form. Don’t put it off thinking that your injuries may get better or that your health insurance will cover the accident. First, filing the application does not obligate you to commence a claim. Second, most health insurance do not cover a personal injury resulting from a car accident. Filing the form simply protects your rights.
Additionally, make sure that you send the form to the correct insurance company. Even if the accident was the other car’s fault, the No-Fault Application gets sent to the insurance carrier for the car you were in.
There are occasions where a pedestrian may not be able to ascertain the insurance company of the car that struck him or a driver of a car is particularly uncooperative and will not provide the information. First, try to get a copy of the police report. The police report should have a three digit code which will tell you the insurance carrier. If you still cannot find the insurance company, the new regulations do allow you to provide written proof of a “clear or reasonable” reason for missing the deadline. But, the insurance companies are largely responsible for determining what is “clear or reasonable” so don’t count on this provision helping you too much.
2. If you cannot determine the insurance company on time, you should, at a minimum, send a notice right away to the New York State Motor Vehicle Accident Indemnification Corporation (MVAIC). MVAIC is a state run agency which steps into the shoes of the insurance company where there is no insurance. If you find out the identity of the insurance company after you file with MVAIC, you may always withdraw your claim with MVAIC. The consumer should not be lulled into a false sense of security, however. MVAIC does not pay claims lightly. It is a state agency and is full of bureaucratic paperwork.
3. If you are claiming lost earnings and out of pocket expenses, you will need to take additional steps to ensure payment of your claim. First, for lost earnings, you must make sure that your employer sends in proof of your wages, disability and loss of income within ninety (90) days of the accident. You may need to be on top of your boss to get these documents filed. Remember, under No-Fault you are entitled to receive 80% of your accident related lost earnings up to $2000 a month paid over a maximum of three years.
Additionally, save all your receipts for car service, personal assistance, etc. Insurance carriers won’t take your word for how much money you spent for accident related out of pocket expenses. So, get receipts for everything. Make photocopies and submit the copies on a weekly basis. You should always confirm that they were received by the claims representative. If there is any question, make another set of copies and send them again. These out of pocket expenses often get ignored at first by the insurance company because they know that it is the first type of expense that the consumer may forget about. Stay on top of it and you increase your chances of recouping the money you spent.
How do I know if I am eligible to receive No-Fault benefits?
Anyone who is injured in a motor vehicle accident, struck by a car or injured in some way by the use or operation of a motor vehicle is an “eligible injured person” and will be covered by No-Fault. Coverage does not apply to people operating or passengers on a motorcycle but does apply to pedestrians hit by a motorcycle or motor vehicle.
How do I apply for my No-Fault benefits?
A No-Fault Application must be filed with the No-Fault carrier within 30 days of the date of the accident. An application form is attached. After the accident, immediately request a NO-FAULT APPLICATION from your insurance company. You will be given a claim number, the name and address of a claim representative to whom you or your medical provider can send documents.
How do my healthcare providers get paid?
Let your medical care provider know that your injuries were caused by an automobile accident. You will be asked to provide the No-Fault insurance information to them and they will provide you with an ASSIGNMENT OF BENEFITS FORM like the one attached, for you to sign. As a result, they will be able to submit their bills directly to the No-Fault Insurance Company, and you will have one less thing to worry about.
How do I get reimbursed for Travel Expenses, Household Help and Prescriptions?
You must collect bills or receipts and submit them to the carrier within 45 days of the travel or service. Failure to so do could result in a denial of benefits by the insurance carrier for failure to comply with policy conditions. Make sure you indicate the claim number on all of your documentation. Do not allow any of the providers of transportation, household help or prescriptions to make these claims on your behalf.
You may wish to have an attorney assist you in filling out the forms required and providing the No Fault insurance company with supporting documentation.
Travel Expenses: The insurance carrier will reimburse you for travel expenses to and from your health care provider whether it is by ambulette, cab, car service, bus or train. If you drive, the insurance company will reimburse you for your mileage to and from your medical provider. You must indicate the name of the medical provider, the date of the office visit and the number of round trip miles. At present, the IRS has set the reimbursement rate for medical transportation at .19¢ per mile. Your mileage reimbursement rate will increase to .27¢ per mile as of July 1, 2008. Use the attached mileage form below to submit your medical travel expense information to the insurance company.
Household Help: The No-Fault carrier will pay for someone to assist with household chores you are unable to perform as a result of your injuries. Your doctor must provide you with a letter stating the household help is medically necessary. In addition, you must submit a letter signed by you and by the person who is providing the household help, indicating the dates this person has assisted you and what they did. Use the attached household help form to submit to the insurance company.
Prescriptions: Before you submit the copies of your prescription receipts to the No-Fault carrier, write the name of the doctor who prescribed the medicine, the name of the medication and your claim number on the receipt. Prescription receipts must be timely submitted to No-Fault carrier to receive reimbursement. Use the attached prescription claim form to submit to the insurance company.
The No Fault Carrier is only required to pay a total of $25.00 per day for travel expenses and household help combined for a period of 1 year from the date of the accident, provided that the proper documentation was been submitted to the no-fault carrier.
How do I get reimbursed for my lost earnings from work?
You must submit a written claim for work loss benefits to the insurance company no later than 90 days after the work loss commences. Failure to so do could result in a denial of coverage by the insurance carrier for failure to comply with policy conditions.
Your employer must fill out an Employer’s Wage Verification Report. In addition, your health care provider must fill out a Verification of Attending Physician stating you are unable to work because of your injury from the accident. Both of these forms must be timely mailed to the No-Fault insurance carrier.
Note: If you are self-employed, you must fill out a form called a Verification of Self-Employment Income. You must submit this form to the No-Fault insurance company along with copies of your previous 2 years income tax returns.
How long will New York State Disability pay me if I am unable to work?
Disability will pay you for twenty-six (26) weeks assuming you can prove your disability and it is verified by your doctor and employer (not including the 1st week you are disabled).
Who will pay me for the first week I am unable to work?
The No-Fault Insurance carrier will pay you for the first week you are disabled from working.
Who will pay me if I am not able to work after the disability payments run out (after 26 weeks)?
The No-Fault insurance company will continue to pay lost earnings up to three (3) years from the date of the accident as long as your doctor has said that you are unable to work because of your injury from this accident or until you have exhausted $50,000 in combined lost earnings and medical payments. The No-Fault insurance carrier can request proof of your disability every 30 days and may stop paying your lost earnings if their doctor examines you and finds that you are no longer disabled.
What will the No-Fault carrier pay if the accident results in death?
The No-Fault insurance Company is required to pay what is called a Death Benefit in the amount of $2,000.00. You must provide the No-Fault carrier with a copy of the death certificate and advise them of the name of the person who has been appointed to handle deceased person’s estate. .
What happens if the No Fault Carrier schedules me for medical examinations?
The no fault insurance company has the legal right to request that you attend one or more Medical Examinations (Commonly referred to as IME’s). You and your attorney, if you have retained one, will receive a letter giving notice of the date, time and place of the medical examination(s). You may postpone the first round of scheduled appointments however, you should not miss the rescheduled examinations, as your benefits may be denied back to the date of the accident. In most cases, after conducting the medical examination, the doctors will advise the no fault insurance company that it is no longer medically necessary for you to continue any therapy or require household help. Based upon this medical evaluation, the insurance company will deny further benefits.
How long can I expect to wait before the insurance company pays me the money they owe me?
The law provides that the No-Fault carrier has up to 30 calendar days to pay or deny a claim from the date they receive all of the information needed to make a decision. The carrier can delay the payment or denial of a claim if they have followed strict timelines and sent appropriate notification to you that they are delaying the claim pending receipt of more information
What can I do if the No Fault Carrier Fails to pay my Bills or sends me a denial of benefits?
If you do not receive your benefits, you have the right to dispute any refusal to pay or denial of claim by submitting a demand for arbitration to the American Arbitration Association. [See hyperlink]It is recommended that you submit all insurance company denials to your attorney. A lawyer with experience in No Fault litigation can review these denials and advise you whether they should be arbitrated.