No-Fault Guide

Motor vehicle drivers and passengers as well as pedestrians and bicyclist are entitled to receive no-fault insurance benefits provided that their injuries arise out of the use or operation of a motor vehicle.  However, motorcyclists are specifically excluded from receiving no-fault benefits.  Additionally, those who are injured as a result of operating a vehicle in an intoxicated state are likewise not entitled to receive no-fault benefits.

In order to protect your rights to medical, wage, and other expenses, you must notify your insurance company of the accident as soon as possible. If you were a passenger in another person’s vehicle, they must notify their insurance company that you were a passenger and that you were injured. If you were a pedestrian or bicyclist, your benefits will come from the car that struck you. If you do not know who the defendant is, the police report will provide you with the defendant’s name and address.  With that information, your attorney can then conduct a search to find the name of the defendant’s insurance carrier.

Once you notify the appropriate insurance company, a no-fault application will be sent to you. No-fault applications are required to be completed and submitted within 30 days of the date of the accident.  If you do not submit the application within that time frame, you must provide the insurance company with a “clear and reasonable justification for the delay.”  It is therefore important to remember that it is not sufficient to simply report the accident over the phone as the failure to submit the no-fault application within the required 30 days of the date of the accident will give the insurance company a basis to deny all of your no-fault benefits.

If you were either a passenger or a pedestrian/bicyclist involved in an accident and you or anyone in your home owns a car that is insured, you should also notify that particular insurance company of the accident as well. You will need to follow the same procedure for filing this additional application within thirty (30) days. The advantage of filing for additional benefits is that there are limits to the amount of medical payments and wage payments to be made under any given policy. If your benefits from one policy run out, you may be able to make a claim against your own policy or another policy in your home for $50,000.00 in additional benefits.

If your doctor tells you that cannot work because of the accident, you should also file a New York State Disability form with your employer. Generally, you will receive this form with your no-fault application, but if you don’t, you can obtain one from your employer. There are three (3) sections to the form. The first is for you to fill out, the second is to be filled out by your doctor and the third is to be filled out by your employer. Your employer should submit the application to their disability insurance company on your behalf. Payments will be calculated and begin following a one (1) week waiting period.

No-fault is responsible for paying all of your reasonable medical expenses related to an accident. Medical expenses submitted to no-fault are paid at the no-fault rate. You are not responsible for the difference between what the provider bills to the insurance company and what no-fault actually pays them. The only exception is when no-fault completely denies a particular payment in which case you are then responsible for that payment. Each time you see a new medical provider, whether it is a doctor, hospital, radiology department, or any other medical provider, you should provide them with the insurance company name to whom they are to send the bill along with the claim number, if one has been assigned.  Any medical bills that are sent to you directly, should be sent to the insurance company immediately. The bills must be submitted within 45 days of the date of service or you will become personally responsible for paying them at the full rate.

If you are disabled as result of an automobile accident and you were employed at the time, you are entitled to collect up to 80% of your wages from a combination of no-fault and New York State Disability payments for up to three years from the date of the accident. If you are claiming lost wages, you must inform the insurance company of your claim within thirty (30) days of the first date that you are unable to work. In order to make this claim, you must obtain a medical statement of disability from your physician for every month that you claim. These will need to be submitted to the insurance company or they will not issue your monthly check. If you go back to work and then your physician takes you back out of work in relation of the accident, you must again notify the insurance company of the new claim. Generally, the maximum amount available from no-fault is $2,000.00 per month. New York State Disability will pay up to $170.00 per week. Since you are only entitled to receive disability for a total of 26 weeks, you should notify the no-fault carrier immediately if your disability payments run out. Your no-fault payments will then be adjusted to reflect the amount that you were receiving from disability.

Once you make a no-fault claim, the insurance company is entitled to have you examined by an independent medical doctor. It is important to realize that these doctors are being paid by the insurance companies for their opinion and therefore, are not as neutral as we would hope. The purpose of the exam is generally to try to cut off your benefits. If their doctor says that you no longer need medical treatment or that you can return to work, those benefits will no longer be paid. In order to deny your benefits for a particular type of care, the company must have you examined by the same type of doctor that you are seeing.  For example, if you are treating with a chiropractor, the examining insurance company doctor would also have to be a chiropractor. In this instance, only a chiropractor would be able to suspend your chiropractic benefits. If your chiropractic benefits are terminated as a result of the exam, you can still treat with other types of providers, such as an orthopedic doctor, neurologist, pain management doctor, or physical therapists.

Once the insurance company issues a denial for a particular type of care, they will no longer pay for that care. You then have the option of continuing the care and paying for it yourself, or seeking some other type of care. In some rare instances, your attorney can successfully fight to get your benefits reinstated. In other instances, your private health insurance may be willing to pay for the services, but they are then entitled to put a lien against your file in order to be reimbursed at the end of your lawsuit. The most important thing to remember about IME’s is that you must submit to these exams or the insurance company will immediately cut off ALL of your no-fault benefits.  Once you are scheduled for an IME, contact your attorney who will offer advice on how to conduct yourself during the exam and if deemed necessary, will attend the examination with you.

No-fault will reimburse you for your mileage incurred to and from all medical providers. This would include, but is not limited to, hospitals, physicians, chiropractors, radiology departments, physical therapists, and insurance doctor exams. In order to be reimbursed for these expenses, you must submit a list of mileage within 90 days of the date that you received the treatment. You must provide the date of the visit, the address that you came from, the address and provider who you visited, as well as the round trip mileage. If you have to take a cab to the medical provider or have to pay someone to take you, be sure to get a signed receipt. You may be entitled to up to $25.00 per day for this type of service. Once the insurance company verifies that you were actually treated on those dates, they will issue you a check for mileage. The only restriction on this benefit is that the insurance company must only pay mileage for a period of one (1) year following the accident.

If you are disabled as a result of the accident, and your doctor recommends it, you may be able to collect up to $25.00 per day for household help and/or childcare assistance for up to one (1) year following the accident. Keep in mind that mileage is considered a miscellaneous expense, so if for example you are collecting $25.00 per day for childcare, you won’t also be able to collect mileage on that same day. In order to collect for household or childcare expenses, you must first provide a note from your doctor that indicates the need for this type of help. The second requirement is that you must provide them with the name, address, social security number and a signed receipt of payment from the person providing services. This can be from a relative, but not from someone who already resides in your household. This claim also must be made within ninety (90) days of the date of service.

Sometimes, an injured person will feel that they have nearly recovered from an accident. They may still have occasional aches and pains, but may no longer go to see a doctor. Occasionally, that person may need additional treatment and/or surgery one or more years following the accident. It is important to keep in mind that if you go for more than one year without seeing a doctor for your accident related complaints, the insurance company will deny the bills when you resume treatment. Therefore, if you are still entitled to no-fault benefits and find that you still have any complaints, it is very important that you see a doctor at least every couple of months in order to preserve your benefits for future use.

If you are a passenger, pedestrian or bicyclist and you were riding in or otherwise involved in an accident with an uninsured motor vehicle your remedy is to make a claim with the New York State Motor Vehicle Accident Indemnification Corporation (MVAIC). If your claim is accepted by the MVAIC, you will be entitled to up to the state minimum of $50,000.00 in benefits. In order to establish such a claim, you will be required to do many of the same things as you would to make a normal no-fault claim. As soon as you know that the motor vehicle is uninsured, you must notify MVAIC of the accident. In addition, you must also provide a completed no-fault application and provide written proof that neither you nor anyone living in your household owns an insured motor vehicle. If you are a passenger, pedestrian or bicyclist, you must also provide written proof that the offending vehicle was uninsured as well. It often takes several months for the claim to be accepted and for your expenses to start being paid by MVAIC. Because of the length of time and difficulty involved in establishing the claim, this remedy should be your very last resort.

DO’S

• Immediately notify your insurance company that you were injured in an accident.
• File your No-Fault application no later than 30 days following the accident. By failing to do so, some or all of your benefits may be denied.
• Write down you claim number and the adjuster’s name. Provide that information to every new medical provider that you see.
• Give your physician an accurate history of the accident and include all physical complaints that you are currently experiencing as well as any that you experienced at the time of the accident.
• Keep track of your mileage and receipts for household help. You must submit those to the insurance company within 90 days of the date of service.
• Keep track of all medical bills and prescription receipts. You must submit those within 45 days of the date of treatment.
• Attend all independent medical examinations (IME) scheduled by the insurance company. If you miss an examination, it may result in a denial of ALL your benefits.
• If you are off of work due to injuries, obtain a disability slip from your physician every 30 days and submit it to the insurance company.
• Notify our office of any change in address, phone number, disability, and work status.

DON’TS

• Discuss your case with the insurance adjuster once you have retained an attorney. Keep our firm telephone number and your attorney’s name handy to provide it to the insurance adjuster.
• Fail to turn in your medical bills within 45 days of the date of treatment. In doing so, you become responsible for your own medical bills and their payment.