NEW YORK STATE
INSURANCE DEPARTMENT
REGULATION NO. 68
(11 NYCRR 65)
REGULATIONS IMPLEMENTING THE COMPREHENSIVE
MOTOR VEHICLE INSURANCE REPARATIONS ACT
I, Gregory V. Serio, Acting Superintendent of Insurance of the State of New
York, pursuant to the authority granted by sections 201, 301, 2601, 5221 and article
51 of the Insurance Law and section 2407 of the Vehicle and Traffic Law, do hereby
repeal Part 65 of Title 11 of the Official Compilation of Codes, Rules and
Regulations of the State of New York (Regulation No. 68), and do hereby
promulgate the following new Part 65 and Subparts 65-1, 65-2, 65-3 and 65-4 of
Title 11 of the Official Compilation of Codes, Rules and Regulations of the State of
New York (Regulation No. 68), to take effect on September 1, 2001 after publication
in the State Register.
(All Matter Is New)
Subpart 65-1 Prescribed Policy Endorsements
Subpart 65-2 Rights and Liabilities of Self-insurers
Subpart 65-3 Claims for Personal Injury Protection benefits
Subpart 65-4 Arbitration
11 NYCRR 65-1
(Regulation 68-A)
Prescribed Policy Endorsements
65-1.1 Requirements for minimum benefit insurance policies for personal
injuries. (a) Every owner’s policy of liability insurance issued in satisfaction of the
minimum requirements of article 6 or 8 of the Vehicle and Traffic Law and article 51
of the Insurance Law shall contain provisions providing minimum first-party benefits
equal to those set out below in the mandatory personal injury protection
endorsement (New York), or mandatory personal injury protection endorsement -
motorcycles (New York), respectively.
(b) The Mandatory Personal Injury Protection Endorsement (New York) and the
Mandatory Personal Injury Protection Endorsement - Motorcycles (New York) set out
below are approved and promulgated for use by an insurer and, except as provided
in subdivision (c) of this section and section 65-1.7 of this Subpart, must be:
(1) furnished to all new insureds with policies effective on and after
September 1, 2001; and
2
(2) enclosed with the first renewal policies renewed on and after
September 1, 2001.
(c) The Mandatory Personal Injury Protection Endorsement - All-Terrain
Vehicles (New York), set out below is approved and promulgated for use by an
insurer and, except as provided in section 65-1.7 of this Subpart, must be issued
with every liability policy covering an All-Terrain Vehicle as required by section 2407
of article 48-C of the New York Vehicle and Traffic Law and Subpart 64-2 of this Title
and must be:
(1) furnished to all new insureds with policies effective on and after
September 1, 2001; and
(2) enclosed with the first renewal policies renewed on and after
September 1, 2001.
(d) Mandatory Personal Injury Protection Endorsement
MANDATORY PERSONAL INJURY PROTECTION ENDORSEMENT
(New York)
The Company agrees with the named insured, as follows:
Section I
Mandatory Personal Injury Protection
The company will pay first-party benefits to reimburse for basic economic loss
sustained by an eligible injured person on account of personal injuries caused by an
accident arising out of the use or operation of a motor vehicle or a motorcycle during
the policy period and within the United States of America, its territories or
possessions, or Canada.
First-party Benefits
First-party benefits, other than death benefits, are payments equal to basic
economic loss, reduced by the following:
(a) 20 percent of the eligible injured person’s loss of earnings from
work to the extent that an eligible injured person’s basic economic
loss consists of such loss of earnings;
(b) amounts recovered or recoverable on account of personal injury to
an eligible injured person under State or Federal laws providing
social security disability or workers’ compensation benefits, or
3
disability benefits under article 9 of the New York Workers’
Compensation Law;
(c) the amount of any applicable deductible, provided that such
deductible shall apply to each accident, but only to the total of first-
party benefits otherwise payable to the named insured and any
relative as a result of that accident.
Basic Economic Loss
Basic economic loss shall consist of medical expense, work loss, other expense
and, when death occurs, a death benefit as herein provided. Except for such death
benefit, basic economic loss shall not include any loss sustained on account of
death. Basic economic loss of each eligible injured person on account of any single
accident shall not exceed $50,000, except that any death benefit hereunder shall be
in addition thereto.
Medical Expense
Medical expense shall consist of necessary expenses for:
(a) medical, hospital (including services rendered in compliance with
Article 41 of the Public Health Law, whether or not such services are
rendered directly by a hospital), surgical, nursing, dental, ambulance,
X-ray, prescription drug and prosthetic services;
(b) psychiatric, physical and occupational therapy and rehabilitation;
(c) any nonmedical remedial care and treatment rendered in accordance
with a religious method of healing recognized by the laws of New York;
and
(d) any other professional health services.
These medical expenses will not be subject to a time limitation, provided that,
within one year after the date of the accident, it is ascertainable that further medical
expenses may be sustained as a result of the injury. Payments hereunder for
necessary medical expenses shall be subject to the limitations and requirements of
section 5108 of the New York Insurance Law.
Work Loss
Work loss shall consist of the sum of the following losses and expenses, up to a
maximum payment of $2,000 per month for a maximum period of three years from
the date of the accident:
(a) loss of earnings from work which the eligible injured person would have
performed had such person not been injured, except that an employee
who is entitled to receive monetary payments, pursuant to statute or
contract with the employer, or who receives voluntary monetary
4
benefits paid for by the employer, by reason of such employee’s
inability to work because of personal injury arising out of the use or
operation of a motor vehicle or a motorcycle, shall not be entitled to
receive first-party benefits for loss of earnings from work to the extent
that such monetary payments or benefits from the employer do not
result in the employee suffering a reduction in income or a reduction in
such employee’s level of future benefits arising from a subsequent
illness or injury; and
(b) reasonable and necessary expenses sustained by the eligible injured
person in obtaining services in lieu of those which such person would
have performed for income.
Other Expenses
Other expenses shall consist of all reasonable and necessary expenses, other
than medical expense and work loss, up to $25 per day for a period of one year from
the date of the accident causing injury.
Death Benefit
Upon the death of any eligible injured person, caused by an accident to which
this coverage applies, the company will pay to the estate of such person a death
benefit of $2,000.
Eligible Injured Person
Subject to the exclusions and conditions set forth below, an eligible injured
person is:
(a) the named insured and any relative who sustains personal injury arising
out of the use or operation of any motor vehicle;
(b) the named insured and any relative who sustains personal injury arising
out of the use or operation of any motorcycle, while not occupying a
motorcycle;
(c) any other person who sustains personal injury arising out of the use or
operation of the insured motor vehicle in the State of New York while
not occupying another motor vehicle; or
(d) any New York State resident who sustains personal injury arising out of
the use or operation of the insured motor vehicle outside of New York
while not occupying another motor vehicle.
Exclusions
This coverage does not apply to personal injury sustained by:
5
(a) the named insured while occupying, or while a pedestrian through
being struck by, any motor vehicle owned by the named insured with
respect to which the coverage required by the New York
Comprehensive Motor Vehicle Insurance Reparations Act is not in
effect;
(b) any relative while occupying, or while a pedestrian through being struck
by, any motor vehicle owned by the relative with respect to which the
coverage required by the New York Comprehensive Motor Vehicle
Insurance Reparations Act is not in effect;
(c) the named insured or relative while occupying, or while a pedestrian
through being struck by, a motor vehicle in New York State, other than
the insured motor vehicle, with respect to which the coverage required
by the New York Comprehensive Motor Vehicle Insurance Reparations
Act is in effect; however, this exclusion does not apply to personal
injury sustained in New York State by the named insured or relative
while occupying a bus or school bus, as defined in sections 104 and
142 of the New York Vehicle and Traffic Law, unless that person is the
operator, an owner, or an employee of the owner or operator, of such
bus or school bus;
[(d) any person in New York State while occupying the insured motor
vehicle which is a bus or school bus, as defined in sections 104 and
142 of the New York Vehicle and Traffic Law, but only if such person is
a named insured or relative under any other policy providing the
coverage required by the New York Comprehensive Motor Vehicle
Insurance Reparations Act; however, this exclusion does not apply to
the operator, an owner, or an employee of the owner or operator, of
such bus or school bus;]
1
(e) any person while occupying a motorcycle;
(f) any person who intentionally causes his or her own personal injury
2
;
(g) any person as a result of operating a motor vehicle while in an
intoxicated condition or while his ability to operate such vehicle is
impaired by the use of a drug (within the meaning of section 1192 of
the New York Vehicle and Traffic Law);
2
or
(h) any person while:
(1) committing an act which would constitute a felony, or seeking to
avoid lawful apprehension or arrest by a law enforcement officer;
2
(2) operating a motor vehicle in a race or speed test;
2
1
Language in brackets may be deleted if the insured motor vehicle is not a bus or school bus.
2
These exclusions may be deleted, in the event the Company wishes to provide coverage
under the indicated circumstances.
6
(3) operating or occupying a motor vehicle known to that person to be
stolen;
2
or
(4) repairing, servicing or otherwise maintaining a motor vehicle if such
conduct is within the course of a business of repairing, servicing or
otherwise maintaining a motor vehicle and the injury occurs on the
business premises;
3
(i) the named insured or relative while not occupying a motor vehicle or a
motorcycle when struck by a motorcycle in New York State with respect
to which the coverage required by the New York Comprehensive Motor
Vehicle Insurance Reparations Act is in effect;
(j) any New York State resident other than the named insured or relative
injured through the use or operation of the insured motor vehicle
outside of New York State if such resident is the owner or a relative of
the owner of a motor vehicle insured under another policy providing the
coverage required by the New York Comprehensive Motor Vehicle
Insurance Reparations Act;
(k) any New York State resident other than the named insured or relative
injured through the use or operation of the insured motor vehicle
outside of New York State if such resident is the owner of a motor
vehicle for which the coverage required by the New York
Comprehensive Motor Vehicle Insurance Reparations Act is not in
effect.
Other Definitions
When used in reference to this coverage:
(a) the “insured motor vehicle” means a motor vehicle owned by the named
insured and to which the bodily injury liability insurance of this policy
applies and for which a specific premium is charged;
(b) “motorcycle” means a vehicle as defined in section 123 of the New York
Vehicle and Traffic Law and which is required to carry financial security
pursuant to article 6, 8 or 48-A of the Vehicle and Traffic Law;
(c) “motor vehicle” means a motor vehicle, as defined in section 311 of the
New York Vehicle and Traffic Law, and also includes fire and police
vehicles, but shall not include any motor vehicle not required to carry
financial security pursuant to article 6, 8 or 48-A of the Vehicle and
Traffic Law, or a motorcycle as defined above;
3
These exclusions may be deleted, in the event the Company wishes to provide coverage
under the indicated circumstances.
7
(d) “named insured” means the person or organization named [in the
declarations];
4
(e) “occupying” means in or upon or entering into or alighting from;
(f) “personal injury” means bodily injury, sickness or disease;
(g) “relative” means a spouse, child, or other person related to the named
insured by blood, marriage, or adoption (including a ward or foster
child), who regularly resides in the insured’s household, including any
such person who regularly resides in the household, but is temporarily
living elsewhere; and
(h) “use or operation” of a motor vehicle or a motorcycle includes the
loading or unloading of such vehicle.
Conditions
Action Against Company. No action shall lie against the Company unless, as a
condition precedent thereto, there shall have been full compliance with the terms of
this coverage.
Notice. In the event of an accident, written notice setting forth details sufficient
to identify the eligible injured person, along with reasonably obtainable information
regarding the time, place and circumstances of the accident, shall be given by, or on
behalf of, each eligible injured person, to the Company, or any of the Company’s
authorized agents, as soon as reasonably practicable, but in no event more than 30
days after the date of the accident, unless the eligible injured person submits written
proof providing clear and reasonable justification for the failure to comply with such
time limitation. If an eligible injured person or that person’s legal representative
institutes a proceeding to recover damages for personal injury under section 5104(b)
of the New York Insurance Law, a copy of the summons and complaint or other
process served in connection with such action shall be forwarded as soon as
practicable to the Company or any of the Company’s authorized agents by such
eligible injured person or that person’s legal representative.
Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the
case of a claim for health service expenses, the eligible injured person or that
person’s assignee or representative shall submit written proof of claim to the
Company, including full particulars of the nature and extent of the injuries and
treatment received and contemplated, as soon as reasonably practicable but, in no
event later than 45 days after the date services are rendered. The eligible injured
person or that person’s representative shall submit written proof of claim for work
loss benefits and for other necessary expenses to the Company as soon as
reasonably practicable but, in no event, later than 90 days after the work loss is
incurred or the other necessary services are rendered. The foregoing time limitations
for the submission of proof of claim shall apply unless the eligible injured person or
that person’s representative submits written proof providing clear and reasonable
4
Companies may substitute the appropriate term, reference or language for the matter set out
in brackets.
8
justification for the failure to comply with such time limitation. Upon request by the
Company, the eligible injured person or that person’s assignee or representative
shall:
(a) execute a written proof of claim under oath;
(b) as may reasonably be required submit to examinations under oath by
any person named by the Company and subscribe the same;
(c) provide authorization that will enable the Company to obtain medical
records; and
(d) provide any other pertinent information that may assist the Company in
determining the amount due and payable.
The eligible injured person shall submit to medical examination by physicians
selected by, or acceptable to, the Company, when, and as often as, the Company
may reasonably require.
Arbitration. In the event any person making a claim for first-party benefits and
the Company do not agree regarding any matter relating to the claim, such person
shall have the option of submitting such disagreement to arbitration pursuant to
procedures promulgated or approved by the Superintendent of Insurance.
Reimbursement and Trust Agreement. To the extent that the Company pays
first-party benefits, the Company is entitled to the proceeds of any settlement or
judgment resulting from the exercise of any right of recovery for damages for
personal injury under section 5104(b) of the New York Insurance Law. The
Company shall have a lien upon any such settlement or judgment to the extent that
the Company has paid first-party benefits. An eligible injured person shall:
(a) hold in trust, for the benefit of the Company, all rights of recovery which
that person shall have for personal injury under section 5104(b) of the
New York Insurance Law;
(b) do whatever is proper to secure, and shall do nothing to prejudice, such
rights; and
(c) execute, and deliver to the Company, instruments and papers as may
be appropriate to secure the rights and obligations of such person and
the Company established by this provision.
An eligible injured person shall not compromise an action to recover damages
brought under section 5104(b) of the New York Insurance Law, except:
(a) with the written consent of the Company;
(b) with approval of the court; or
(c) where the amount of the settlement exceeds $50,000.
9
Other Coverage. Where more than one source of first-party benefits required
by article 51 of the New York Insurance Law and article 6 or 8 of the New York
Vehicle and Traffic Law is available and applicable to an eligible injured person in
any one accident, this Company is liable to an eligible injured person only for an
amount equal to the maximum amount that the eligible injured person is entitled to
recover under this coverage, divided by the number of available and applicable
sources of required first-party benefits. An eligible injured person shall not recover
duplicate benefits for the same elements of loss under this coverage or any other
mandatory first-party motor vehicle or no-fault motor vehicle insurance coverage
issued in compliance with the laws of another state.
If the eligible injured person is entitled to benefits under any such mandatory
first-party motor vehicle or no-fault motor vehicle insurance for the same elements of
loss under this coverage, this Company shall be liable only for an amount equal to
the proportion that the total amount available under this coverage bears to the sum
of the amount available under this coverage and the amount available under such
other mandatory insurance for the common elements of loss. However, where
another state’s mandatory first-party or no-fault motor vehicle insurance law provides
unlimited coverage available to an eligible injured person for an element of loss
under this coverage, the obligation of this Company is to share equally for that
element of loss with such other mandatory insurance until the $50,000, or $75,000 if
Optional Basic Economic Loss (OBEL) coverage is purchased, limit of this coverage
is exhausted by the payment of that element of loss and any other elements of loss.
Section II
Excess Coverage
If motor vehicle medical payments coverage or any disability coverages or
uninsured motorists coverage are afforded under this policy, such coverages shall
be excess insurance over any Mandatory PIP, OBEL or Additional PIP benefits paid
or payable, or which would be paid or payable but for the application of a deductible,
under this or any other motor vehicle No-Fault insurance policy.
Section III
Constitutionality
If it is conclusively determined by a court of competent jurisdiction that the New
York Comprehensive Motor Vehicle Insurance Reparations Act, or any amendment
thereto, is invalid or unenforceable in whole or in part, then, subject to the approval
of the Superintendent of Insurance, the Company may amend this policy and may
also recompute the premium for the existing or amended policy.
These amendments and recomputations will be effective retroactively to the
date that such act or any amendment is deemed to be invalid or unenforceable in
whole or in part.
* * *
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(e) Mandatory Personal Injury Protection Endorsement - Motorcycles
MANDATORY PERSONAL INJURY PROTECTION ENDORSEMENT
MOTORCYCLES - (New York)
5
The company agrees with the named insured as follows:
Section I
Mandatory Personal Injury Protection
The Company will pay first-party benefits to reimburse for basic economic loss
sustained by an eligible injured person on account of personal injuries caused by an
accident arising out of the use or operation of the insured motorcycle. This coverage
applies only to motorcycle accidents which occur during the policy period and within
the State of New York.
Eligible Injured Person
An eligible injured person is any person who sustains a personal injury arising
out of the use or operation of the insured motorcycle while not occupying the insured
motorcycle, any other motorcycle or a motor vehicle.
First-party Benefits
First-party benefits, other than death benefits, are payments equal to basic
economic loss, reduced by the following:
(a) 20 percent of the eligible injured person’s loss of earnings from work to
the extent that an eligible injured person’s basic economic loss consists
of such loss of earnings;
(b) amounts recovered or recoverable on account of personal injury to an
eligible injured person under State or Federal laws providing social
security disability or workers’ compensation benefits, or disability
benefits under article 9 of the New York Workers’ Compensation Law.
Basic Economic Loss
Basic economic loss shall consist of medical expense, work loss, other expense
and, when death occurs, a death benefit as herein provided. Except for such death
benefit, basic economic loss shall not include any loss sustained on account of
death. Basic economic loss of each eligible injured person on account of any single
accident shall not exceed $50,000, except that any death benefit hereunder shall be
in addition thereto.
5
This endorsement shall be issued only for insured motorcycles.
11
Medical Expense
Medical expense shall consist of necessary expenses for:
(a) medical, hospital (including services rendered in compliance with
article 41 of the Public Health Law, whether or not such services are
rendered directly by a hospital), surgical, nursing, dental, ambulance,
X-ray, prescription drug and prosthetic services;
(b) psychiatric, physical and occupational therapy and rehabilitation;
(c) any nonmedical remedial care and treatment rendered in accordance
with a religious method of healing recognized by the laws of New York;
and
(d) any other professional health services.
These medical expenses will not be subject to a time limitation, provided that
within one year after the date of the accident it is ascertainable that further medical
expenses may be sustained as a result of the injury. Payments hereunder for
necessary medical expenses shall be subject to the limitations and requirements of
section 5108 of the New York Insurance Law.
Work Loss
Work loss shall consist of the sum of the following losses and expenses, up to a
maximum payment of $2,000 per month for a maximum period of three years from
the date of the accident:
(a) loss of earnings from work which the eligible injured person would
have performed had such person not been injured, except that an
employee who is entitled to receive monetary payments, pursuant to
statute or contract with the employer, or who receives voluntary
monetary benefits paid for by the employer, by reason of such
employee’s inability to work because of personal injury arising out of
the use or operation of a motorcycle, shall not be entitled to receive
first-party benefits for loss of earnings from work to the extent that
such monetary payments or benefits from the employer do not result in
the employee suffering a reduction in income or a reduction in such
employee’s level of future benefits arising from a subsequent illness or
injury; and
(b) reasonable and necessary expenses sustained by the eligible injured
person in obtaining services in lieu of those which such person would
have performed for income.
Other Expenses
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Other expenses shall consist of all reasonable and necessary expenses, other
than medical expense and work loss, up to $25 per day for a period of one year from
the date of the accident causing injury.
Death Benefit
Upon the death of any eligible injured person, caused by an accident to which
this coverage applies, the Company will pay to the estate of such person a death
benefit of $2,000.
Exclusions
6
This coverage does not apply:
(a) to a personal injury sustained by any person who intentionally causes
his own personal injury;
(b) to a personal injury sustained by any person while committing an act
which would constitute a felony, or seeking to avoid lawful
apprehension or arrest by a law enforcement officer; or
(c) to a personal injury sustained by a person while repairing, servicing, or
otherwise maintaining a motor vehicle or motorcycle, if such conduct is
within the course of a business of repairing, servicing, or otherwise
maintaining a motor vehicle or motorcycle and the injury occurs on the
business premises.
Other Definitions
When used in reference to this coverage:
(a) “insured motorcycle” means a motorcycle owned by the named insured
and to which the bodily injury liability insurance of this policy applies
and for which a specific premium is charged;
(b) “motorcycle” means a vehicle as defined in section 123 of the New
York Vehicle and Traffic Law, and which is required to carry financial
security pursuant to article 6, 8 or 48-A of the Vehicle and Traffic Law;
(c) “motor vehicle” means a motor vehicle, as defined in section 311 of the
New York Vehicle and Traffic Law, and also includes fire and police
vehicles, but shall not include any motor vehicle not required to carry
financial security pursuant to article 6, 8 or 48-A of the Vehicle and
Traffic Law, or a motorcycle as defined above;
(d) “named insured” means the person or organization named [in the
declaration];
7
6
These exclusions may be deleted, in the event the Company wishes to provide coverage
under the indicated circumstances.
13
(e) “occupying” means in or upon or entering into or alighting from;
(f) “personal injury” means bodily injury, sickness or disease;
(g) “use or operation” of a motor vehicle or motorcycle includes the
loading or unloading of such vehicle.
Conditions
Action Against Company. No action shall lie against the Company unless, as a
condition precedent thereto, there shall have been full compliance with the terms of
this coverage.
Notice. In the event of an accident, written notice setting forth details sufficient
to identify the eligible injured person, along with reasonably obtainable information
regarding the time, place and circumstances of the accident, shall be given by, or on
behalf of, each eligible injured person, to the Company, or any of the Company’s
authorized agents, as soon as reasonably practicable, but in no event more than 30
days after the date of the accident, unless the eligible injured person submits written
proof providing clear and reasonable justification for the failure to comply with such
time limitation. If an eligible injured person or that person’s legal representative
institutes a proceeding to recover damages for personal injury under section 5104(b)
of the New York Insurance Law, a copy of the summons and complaint or other
process served in connection with such action shall be forwarded as soon as
practicable to the Company or any of the Company’s authorized agents by such
eligible injured person or that person’s legal representative.
Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the
case of a claim for health service expenses, the eligible injured person or that
person’s assignee or representative shall submit written proof of claim to the
Company, including full particulars of the nature and extent of the injuries and
treatment received and contemplated, as soon as reasonably practicable but, in no
event later than 45 days after the date services are rendered. The eligible injured
person or that person’s representative shall submit written proof of claim for work
loss benefits and for other necessary expenses to the Company as soon as
reasonably practicable but, in no event, later than 90 days after the work loss is
incurred or the other necessary services are rendered. The foregoing time limitations
for the submission of proof of claim shall apply unless the eligible injured person
submits written proof providing clear and reasonable justification for the failure to
comply with such time limitation. Upon request by the Company, the eligible injured
person or that person’s assignee or representative shall:
(a) execute a written proof of claim under oath;
(b) as may reasonably be required submit to examinations under oath by
any person named by the Company and subscribe the same;
7
Companies may substitute the appropriate term, reference or language for the matter set out
in brackets.
14
(c) provide authorization that will enable the Company to obtain medical
records; and
(d) provide any other pertinent information that may assist the Company in
determining the amount due and payable.
The eligible injured person shall submit to medical examination by physicians
selected by, or acceptable to, the Company when, and as often as, the Company
may reasonably require.
Arbitration. In the event any person making a claim for first-party benefits and
the Company do not agree regarding any matter relating to the claim, such person
shall have the option of submitting such disagreement to arbitration pursuant to
procedures promulgated or approved by the Superintendent of Insurance.
Reimbursement and Trust Agreement. To the extent that the Company pays
first-party benefits, the Company is entitled to the proceeds of any settlement or
judgment resulting from the exercise of any right of recovery for damages for
personal injury under section 5104(b) of the New York Insurance Law. The
Company shall have a lien upon any such settlement or judgment to the extent that
the Company has paid first-party benefits. An eligible injured person shall:
(a) hold in trust, for the benefit of the Company, all rights of recovery
which that person shall have for personal injury under section 5104(b)
of the New York Insurance Law;
(b) do whatever is proper to secure, and shall do nothing to prejudice,
such rights; and
(c) execute, and deliver to the Company, instruments and papers as may
be appropriate to secure the rights and obligations of such person and
the Company established by this provision.
An eligible injured person shall not compromise an action to recover damages
brought under section 5104(b) of the New York Insurance Law, except:
(a) with the written consent of the Company;
(b) with approval of the court; or
(c) where the amount of the settlement exceeds $50,000.
Other Coverage. Where more than one source of first-party benefits required
by article 51 of the New York Insurance Law and article 6 or 8 of the New York
Vehicle and Traffic Law is available and applicable to an eligible injured person in
any one accident, this Company is liable to an eligible injured person only for an
amount equal to the maximum amount that the eligible injured person is entitled to
recover under this coverage, divided by the number of available and applicable
sources of required first-party benefits. An eligible injured person shall not recover
duplicate benefits for the same elements of loss under this coverage or any other
15
mandatory first-party motor vehicle or no-fault motor vehicle insurance coverage
issued in compliance with the laws of another state.
If the eligible injured person is entitled to benefits under any such mandatory
first-party motor vehicle or no-fault motor vehicle insurance for the same elements
of loss under this coverage, this Company shall be liable only for an amount equal to
the proportion that the total amount available under this coverage bears to the sum
of the amount available under this coverage and the amount available under such
other mandatory insurance for the common elements of loss. However, where
another state’s mandatory first-party or no-fault motor vehicle insurance law provides
unlimited coverage available to an eligible injured person for an element of loss
under this coverage, the obligation of this Company is to share equally for that
element of loss with such other mandatory insurance until the $50,000, or $75,000 if
Optional Basic Economic Loss (OBEL) coverage is purchased, limit of this coverage
is exhausted by the payment of that element of loss and any other elements of loss.
Section II
Excess Coverage
If medical payments coverage or any disability coverages or uninsured motorists
coverage are afforded under this policy, such coverages shall be excess insurance
over any Mandatory PIP, OBEL or Additional PIP benefits paid or payable, or which
would be paid or payable but for the application of a deductible under this or any
other motor vehicle No-Fault insurance policy.
Section III
Constitutionality
If it is conclusively determined by a court of competent jurisdiction that the New
York Comprehensive Motor Vehicle Insurance Reparations Act, or any amendment
thereto, is invalid or unenforceable in whole or in part, then, subject to the approval
of the Superintendent of Insurance, the Company may amend this policy and may
also recompute the premium for the existing or amended policy.
These amendments and recomputations will be effective retroactively to the
date that such Act or any amendment is deemed to be invalid or unenforceable in
whole or in part.
* * *
(f) Mandatory Personal Injury Protection Endorsement- All-Terrain Vehicles
(ATV)
MANDATORY PERSONAL INJURY PROTECTION ENDORSEMENT
ALL-TERRAIN VEHICLES (ATV)
8
(New York)
8
This endorsement shall be issued only for all-terrain vehicles.
16
The Company agrees with the named insured as follows:
Section I
Mandatory Personal Injury Protection
The company will pay first-party benefits to reimburse for basic economic loss
sustained by an eligible injured person on account of personal injuries caused by an
accident arising out of the use or operation of the insured ATV. This coverage applies
only to ATV accidents which occur during the policy period and on or after January 1,
1987 and within the State of New York.
Eligible Injured Person
An eligible injured person is any person who sustains a personal injury arising out
of the use or operation of the insured ATV while not occupying the insured ATV, any
other ATV, any motorcycle or a motor vehicle.
First-party Benefits
First-party benefits, other than death benefits, are payments equal to basic
economic loss, reduced by the following:
(a) 20 percent of the eligible injured person's loss of earnings from work to
the extent that an eligible injured person's basic economic loss consists
of such loss of earnings;
(b) amounts recovered or recoverable on account of personal injury to an
eligible injured person under State or Federal laws providing social
security disability or workers' compensation benefits, or disability
benefits under article 9 of the New York Workers' Compensation Law.
Basic Economic Loss
Basic economic loss shall consist of medical expense, work loss, other expense
and, when death occurs, a death benefit as herein provided. Except for such death
benefit, basic economic loss shall not include any loss sustained on account of death.
Basic economic loss of each eligible injured person on account of any single accident
shall not exceed $50,000 except that any death benefit hereunder shall be in addition
thereto.
Medical Expense
Medical expense shall consist of necessary expenses for:
(a) medical, hospital, surgical, nursing, dental, ambulance, X-ray,
prescription drug and prosthetic services;
(b) psychiatric, physical and occupational therapy and rehabilitation;
17
(c) any nonmedical remedial care and treatment rendered in accordance
with a religious method of healing recognized by the laws of New York;
and
(d) any other professional health services.
These medical expenses will not be subject to a time limitation, provided that
within one year after the date of the accident it is ascertainable that further medical
expenses may be sustained as a result of the injury. Payments hereunder for
necessary medical expenses shall be subject to the limitations and requirements of
section 5108 of the New York Insurance Law.
Work Loss
Work loss shall consist of the sum of the following losses and expenses, up to a
maximum payment of $2,000 per month for a period of three years from the date of
the accident:
(a) loss of earnings from work which the eligible injured person would have
performed had such person not been injured, except that an employee
who is entitled to receive monetary payments, pursuant to statute or
contract with the employer, or who receives voluntary monetary benefits
paid for by the employer, by reason of such employee's inability to work
because of personal injury arising out of the use or operation of an ATV
shall not be entitled to receive first-party benefits for loss of earnings
from work to the extent that such monetary payments or benefits from
the employer do not result in the employee suffering a reduction in
income or a reduction in such employee's level of future benefits arising
from a subsequent illness or injury; and
(b) reasonable and necessary expenses sustained by the eligible injured
person in obtaining services in lieu of those which such person would
have performed for income.
Other Expenses
Other expenses shall consist of all reasonable and necessary expenses, other
than medical expense and work loss, up to $25 per day for a period of one year from
the date of the accident causing injury.
Death Benefit
Upon the death of any eligible injured person, caused by an accident to which this
coverage applies, the Company will pay to the estate of such person a death benefit of
$2,000.
Exclusions
9
9
These exclusions may be deleted, in the event the Company wishes to provide coverage
under the indicated circumstances.
18
This coverage does not apply:
(a) to a personal injury sustained by any person who intentionally causes his
own personal injury;
(b) to a personal injury sustained by any person while committing an act
which would constitute a felony, or seeking to avoid lawful apprehension
or arrest by a law enforcement officer; or
(c) to a personal injury sustained by a person while repairing, servicing, or
otherwise maintaining a motor vehicle, motorcycle or ATV, if such
conduct is within the course of a business of repairing, servicing, or
otherwise maintaining a motor vehicle, motorcycle or ATV, and the injury
occurs on the business premises.
Other Definitions
When used in reference to this coverage:
(a) the “insured ATV” means an ATV owned by the named insured and to
which the bodily injury liability insurance of this policy applies and for
which a specific premium is charged;
(b) “motorcycle” means a vehicle as defined in section 123 of the New York
Vehicle and Traffic Law, and which is required to carry financial security
pursuant to article 6, 8 or 48-A of the Vehicle and Traffic Law;
(c) “all-terrain vehicle (ATV)” means a vehicle defined in section 2281 of the
New York Vehicle and Traffic Law, which is required to carry financial
security pursuant to articles 48-A and 48-C of the Vehicle and Traffic
Law;
(d) “motor vehicle” means a motor vehicle, as defined in section 311 of the
New York Vehicle and Traffic Law, and also includes fire and police
vehicles, but shall not include any motor vehicle not required to carry
financial security pursuant to article 6, 8 or 48-A of the Vehicle and
Traffic Law, or a motorcycle or ATV, as defined above;
(e) “named insured” means the person or organization named [in the
declaration];
10
(f) “occupying” means in or upon or entering into or alighting from;
(g) “personal injury” means bodily injury, sickness or disease;
(h) “use or operation” of a motor vehicle, motorcycle or ATV includes the
loading or unloading of such vehicle.
10
Companies may substitute the appropriate term, reference or language for the matter set
out in brackets.
19
Conditions
Action Against Company. No action shall lie against the Company, unless, as a
condition precedent thereto, there shall have been full compliance with the terms of
this coverage.
Notice. In the event of an accident, written notice setting forth details sufficient to
identify the eligible injured person, along with reasonably obtainable information
regarding the time, place and circumstances of the accident, shall be given by, or on
behalf of, each eligible injured person, to the Company, or any of the Company's
authorized agents, as soon as reasonably practicable, but in no event more than 30
days after the date of the accident, unless the eligible injured person submits written
proof providing clear and reasonable justification for the failure to comply with such
time limitation. If an eligible injured person or his legal representative institutes a
proceeding to recover damages for personal injury under section 5104(b) of the New
York Insurance Law, a copy of the summons and complaint or other process served in
connection with such action shall be forwarded as soon as practicable to the Company
or any of the Company's authorized agents by such eligible injured person or his legal
representative.
Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the
case of a claim for health service expenses, the eligible injured person or that
person’s assignee or representative shall submit written proof of claim to the
Company, including full particulars of the nature and extent of the injuries and
treatment received and contemplated, as soon as reasonably practicable but, in no
event later than 45 days after the date services are rendered. The eligible injured
person or that person’s representative shall submit written proof of claim for work
loss benefits and for other necessary expenses to the Company as soon as
reasonably practicable but, in no event, later than 90 days after the work loss is
incurred or the other necessary services are rendered. The foregoing time limitations
for the submission of proof of claim shall apply unless the eligible injured person
submits written proof providing clear and reasonable justification for the failure to
comply with such time limitation. Upon request by the Company, the eligible injured
person or that person’s assignee or representative shall:
(a) execute a written proof of claim under oath;
(b) as may reasonably be required submit to examinations under oath by
any person named by the Company and subscribe the same;
(c) provide authorization that will enable the Company to obtain medical
records; and
(d) provide any other pertinent information that may assist the Company in
determining the amount due and payable.
The eligible injured person shall submit to medical examination by physicians
selected by, or acceptable to, the Company, when, and as often as, the Company
may reasonably require.
20
Arbitration. In the event any person making a claim for first-party benefits and the
Company do not agree regarding any matter relating to the claim, such person shall
have the option of submitting such disagreement to arbitration pursuant to procedures
promulgated or approved by the Superintendent of Insurance.
Reimbursement and Trust Agreement. To the extent that the Company pays first-
party benefits, the Company is entitled to the proceeds of any settlement or judgment
resulting from the exercise of any right of recovery for damages for personal injury
under section 5104(b) of the New York Insurance Law. The Company shall have a lien
upon any such settlement or judgment to the extent that the Company has paid first-
party benefits. An eligible injured person shall:
(a) hold in trust, for the benefit of the Company, all rights of recovery which
he shall have for personal injury under section 5104(b) of the New York
Insurance Law;
(b) do whatever is proper to secure, and shall do nothing to prejudice, such
rights; and
(c) execute, and deliver to the Company, instruments and papers as may
be appropriate to secure the rights and obligations of such person and
the Company established by this provision.
An eligible injured person shall not compromise an action to recover damages
brought under section 5104(b) of the New York Insurance Law except:
(a) with the written consent of the Company;
(b) with approval of the court; or
(c) where the amount of the settlement exceeds $50,000.
Other Coverage. Where more than one source of first-party benefits required by
article 51 of the New York Insurance Law and article 6 or 8 of the New York Vehicle
and Traffic Law is available and applicable to an eligible injured person in any one
accident, this Company is liable to an eligible injured person only for an amount equal
to the maximum amount that the eligible injured person is entitled to recover under this
coverage, divided by the number of available and applicable sources of required first-
party benefits. An eligible injured person shall not recover duplicate benefits for the
same elements of loss under this coverage or any other mandatory first-party
automobile or no-fault automobile insurance coverage issued in compliance with the
laws of another state.
If the eligible injured person is entitled to benefits under any such mandatory first-
party automobile or no-fault automobile insurance for the same elements of loss under
this coverage, this Company shall be liable only for an amount equal to the proportion
that the total amount available under this coverage bears to the sum of the amount
available under this coverage and the amount available under such other mandatory
insurance of the common elements of loss. However, where another state's mandatory
21
first-party or no-fault automobile insurance law provides unlimited coverage available
to an eligible injured person for an element of loss under this coverage, the obligation
of this Company is to share equally for that element of loss with such other mandatory
insurance until the $50,000 limit of this coverage is exhausted by the payment of that
element of loss and any other elements of loss.
Section II
Excess Coverage
If medical payments coverage or any disability coverages or uninsured motorists
coverage are afforded under this policy, such coverages shall be excess insurance
over any mandatory or additional personal injury protection benefits paid or payable, or
which would be paid or payable but for the application of a deductible under this or any
other automobile no-fault insurance policy.
Section III
Constitutionality
If it is conclusively determined by a court of competent jurisdiction that the New
York Comprehensive Motor Vehicle Insurance Reparations Act, or any amendment
thereto, is invalid or unenforceable in whole or in part, then, subject to the approval of
the Superintendent of Insurance, the Company may amend this policy and may also
recompute the premium for the existing or amended policy.
These amendments and recomputations will be effective retroactively to the date
that such Act or any amendment is deemed to be invalid or unenforceable in whole or
in part.
* * *
(g) Notwithstanding any of the provisions of these endorsements, the Company
shall provide at least for the payment of first-party benefits pursuant to section 5103
of the Insurance Law, and these endorsements shall be construed as if such
coverage were embodied therein.
65-1.2 Requirements for Optional Basic Economic Loss Coverage. (a) The
Optional Basic Economic Loss Coverage Endorsement (New York), set out below is
approved and promulgated for use by an insurer and, except as provided in section
65-1.7 of this Subpart, must be furnished to all insureds who purchase Optional
Basic Economic Loss (OBEL) coverage.
OPTIONAL BASIC ECONOMIC LOSS COVERAGE ENDORSEMENT
(New York)
The Company agrees with the named insured, subject to all of the provisions,
exclusions and conditions of the MANDATORY PERSONAL INJURY PROTECTION
22
ENDORSEMENT (New York) not expressly modified in this Endorsement, as
follows:
The definition of Basic Economic Loss contained in the MANDATORY PERSONAL
INJURY PROTECTION ENDORSEMENT (New York) or the MANDATORY
PERSONAL INJURY PROTECTION ENDORSEMENT-MOTORCYCLES (New York)
is replaced by the following:
Basic Economic Loss:
Basic economic loss shall consist of medical expense, work loss, other expense
and, when death occurs, a death benefit as herein provided. Except for such death
benefit, basic economic loss shall not include any loss sustained on account of
death. Basic economic loss of each eligible injured person on account of any single
accident shall not exceed $75,000, the last $25,000 of which represents optional
basic economic loss coverage, payable after the first $50,000 of basic economic loss
has been exhausted, that the eligible injured person or that person’s legal
representative may specify will be applied to one of the following four options:
(a) basic economic loss;
(b) loss of earnings from work;
(c) psychiatric, physical or occupational therapy and rehabilitation; or
(d) a combination of options (b) and (c).
Any death benefit hereunder shall be in addition thereto.
Exclusion (c) set forth in the MANDATORY PERSONAL INJURY PROTECTION
ENDORSEMENT (New York) is replaced by the following:
(c) the named insured or relative while occupying, or while a pedestrian
through being struck by, a motor vehicle in New York State, other than
the insured motor vehicle, with respect to which the coverage required
by the New York Comprehensive Motor Vehicle Insurance Reparations
Act is in effect; however, this exclusion does not apply to:
(1) the Optional Basic Economic Loss coverage provided under this
endorsement, unless OBEL coverage is provided by the policy
covering the other motor vehicle; or
(2) to personal injury sustained in New York State by the named
insured or relative while occupying a bus or school bus, as defined
in sections 104 and 142 of the New York Vehicle and Traffic Law,
unless that person is the operator, an owner, or an employee of
the owner or operator, of such bus or school bus.
Election
23
Election of the OBEL option shall be made by the eligible injured person or that
person’s legal representative after such person has incurred expense aggregating
$30,000 in basic economic loss and after receiving the required notices from the
Company that an OBEL election may be made. Failure of the eligible injured person
or that person’s legal representative to respond to the second notice within 15
calendar days after its mailing shall be considered an election by the eligible injured
person to apply OBEL coverage to all elements of basic economic loss. Once made
by the eligible injured person or that person’s legal representative, an OBEL election
cannot be changed. However, if claims payable under OBEL coverage have not yet
been received by the Company, an eligible injured person who has failed to respond
to the second notice in a timely manner may make an election.
Notice
If OBEL coverage is payable under this policy, but Mandatory PIP is being paid
under a policy covering another motor vehicle, then the named insured or relative
shall notify the Company no later than 90 days after Mandatory PIP benefits under
that other policy have been exhausted. The Company shall then send its OBEL
election notice.
(b) The insurer shall in connection with new policy applications offer applicants
OBEL coverage by sending the applicant the following letter:
Dear Applicant:
Optional Basic Economic Loss (OBEL) coverage is being offered to you as an
enhancement of the Basic No-Fault coverage you are presently required to purchase.
But before we describe this coverage, we would like to advise you what benefits Basic
No-Fault coverage does and does not provide.
No-Fault coverage, otherwise known as Personal Injury Protection or "PIP" coverage,
pays for expenses incurred by persons injured in a motor vehicle accident. This
coverage does not pay to repair damage to your automobile.
Basic No-Fault, which you are required by law to purchase, provides coverage of up to
$50,000 per person in benefits for:
1. all necessary doctor and hospital bills and other health service expenses, payable in
accordance with fee schedules established or adopted by the New York State
Insurance Department; and
2. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three
years following the date of accident; and
3. up to $25 per day for a period of one year from the date of the accident for other
reasonable and necessary expenses the injured person may have incurred because of
an injury resulting from the accident, such as the cost of hiring a housekeeper or
necessary transportation expenses to and from a health service provider; and
24
4. a $2,000 death benefit, payable to the estate of a covered person, in addition to the
$50,000 coverage for economic loss described above.
No-Fault benefits will be reduced by other benefits that are payable under Workers'
Compensation, Social Security Disability, New York State Disability, and certain
employer "wage continuation" plans where an employee does not lose any future sick
leave benefits.
[In addition to the basic No-Fault coverage described, higher limits of up to
________________, including payments of up to ____________ for loss of earnings
and up to_____________ for other reasonable and necessary expenses, are available
for purchase upon request.]
11
OPTIONAL COVERAGE AVAILABLE
In addition to Basic No-Fault Coverage, you may also purchase OBEL coverage that
will pay certain expenses, up to $25,000, above the Basic No-Fault limit of $50,000.
OBEL coverage is different from other coverages in that a claimant can select the
kinds of benefits to be paid under OBEL.
If you purchase OBEL coverage and if it appears likely that a claimant will use up the
Basic No-Fault coverage, your insurer will send the claimant a form for the claimant to
choose what expenses the $25,000 in OBEL coverage will be used to pay. Under
No-Fault, a claimant could include you, family members, passengers in your car, or
pedestrians, if injured in an auto accident.
The claimant will be able to choose one of the following four OBEL options and
thereby direct the insurer to pay expenses for:
1. basic economic loss, whether health care expenses, loss of earnings from work, or
other reasonable and necessary expenses;
2. loss of earnings from work;
3. psychiatric, physical or occupational therapy and rehabilitation; or
4. a combination of options 2 and 3.
The additional $25,000 of OBEL coverage will be used only for costs incurred under
the chosen option, which, once selected, the claimant cannot change.
If you have any questions, please contact your company or agent.
65-1.3 Requirements for Additional Personal Injury Protection Coverage.
(a) The Additional Personal Injury Protection Endorsement (New York), set out in
this section, is approved and promulgated and all of the provisions thereof shall, in
accordance with section 2307(b) of the Insurance Law, be deemed to be included in
all additional personal injury protection endorsements in force. This endorsement
11
This Additional PIP language may be deleted at the insurer’s option.
25
contains non-substantive changes from the previously prescribed Additional
Personal Injury Protection Endorsement (New York) and may be substituted for that
endorsement when supplies of that endorsement are exhausted. This endorsement
may be combined with the Mandatory Personal Injury Protection Endorsement (New
York) and other coverages, with appropriate language.
(b) The endorsement set forth in this section may include the following
provision, together with appropriate schedule(s) of named individuals: “It is agreed
that the individual(s) named in this endorsement shall be deemed to be a named
insured under the Mandatory Personal Injury Protection Endorsement (New York)
and, to the extent applicable, this endorsement.”
(c) Additional Personal Injury Protection Endorsement
ADDITIONAL PERSONAL INJURY PROTECTION ENDORSEMENT
(New York)
The Company agrees with the named insured subject to all of the provisions,
exclusions and conditions of the Mandatory Personal Injury Protection
(Endorsement)
12
(New York), not expressly modified in this (Endorsement)
12
as
follows:
Additional Personal Injury Protection
The Company will pay additional first-party benefits to reimburse for extended
economic loss on account of personal injuries sustained by an eligible injured person
and caused by an accident arising out of the use or operation of a motor vehicle or
motorcycle during the policy period. This coverage only applies to motor vehicle
accidents within the United States of America, its territories or possessions, or
Canada.
Eligible Injured Person
Subject to the exclusions and conditions set forth below, an eligible injured
person is:
(a) the named insured and any relative who sustains personal injury
arising out of the use or operation of any motor vehicle;
(b) the named insured and any relative who sustains personal injury
arising out of the use or operation of any motorcycle while not
occupying a motorcycle;
(c) any other person who sustains personal injury arising out of the use or
operation of the insured motor vehicle while occupying the insured
motor vehicle; or
12
Companies may substitute the appropriate term, reference or language for the matter set
out in parenthesis.
26
(d) any other person who sustains personal injury arising out of the use or
operation of any other motor vehicle (other than a public or livery
conveyance) while occupying such other motor vehicle, if such other
motor vehicle is being operated by the named insured or any relative.
Exclusions
This coverage does not apply to personal injury sustained by:
(a) any person while occupying a motor vehicle owned by such person
with respect to which the coverage required by the New York
Comprehensive Motor Vehicle Insurance Reparations Act is not in
effect;
(b) any person while occupying, or while a pedestrian through being
struck by, a motor vehicle owned by the named insured with respect to
which additional personal injury protection coverage is not provided
under this policy;
(c) any relative while occupying, or while a pedestrian through being
struck by, a motor vehicle owned by such relative with respect to which
additional personal injury protection coverage is not provided under
this policy;
(d) any New York State resident other than the named insured or relative
injured through the use or operation of a motor vehicle outside of New
York State if such resident is the owner of a motor vehicle for which
the coverage required by the New York Comprehensive Motor Vehicle
Insurance Reparations Act is not in effect;
(e) any person while occupying a motorcycle;
(f) any person who intentionally causes his own personal injury;
13
(g) any person as a result of operating a motor vehicle while in an
intoxicated condition or while his ability to operate such vehicle is
impaired by the use of a drug (within the meaning of section 1192 of
the New York Vehicle and Traffic Law)
13
; or
(h) any person while:
(i) committing an act which would constitute a felony, or seeking to
avoid lawful apprehension or arrest by a law enforcement officer;
13
(ii) operating a motor vehicle in a race or speed test;
13
(iii) operating or occupying a motor vehicle known to him to be stolen;
or
13
13
These exclusions may be deleted, in the event the Company wishes to provide coverage
under the indicated circumstances.
27
(iv) repairing, servicing, or otherwise maintaining a motor vehicle if
such conduct is within the course of a business of repairing,
servicing or otherwise maintaining a motor vehicle and the injury
occurs on the business premises.
13
Additional First-party Benefits
Additional first-party benefits are payments equal to extended economic loss
reduced by:
(a) 20 percent of the eligible injured person’s loss of earnings from work,
to the extent that the extended economic loss covered by this
[Endorsement]
14
includes such loss of earnings;
(b) amounts recovered or recoverable on account of personal injury to an
eligible injured person under State or Federal laws providing social
security disability or workers’ compensation benefits or disability
benefits under article 9 of the New York Workers’ Compensation law,
which amounts have not been applied to reduce first-party benefits
recovered or recoverable under basic economic loss;
(c) amounts recovered or recoverable by the eligible injured person for
any element of extended economic loss covered by this
[Endorsement]
14
under any mandatory source of first-party automobile
no-fault benefits required by the laws of any state (other than the State
of New York) of the United States of America, its possessions or
territories, or by the laws of any province of Canada.
Extended Economic Loss
Extended economic loss shall consist of the following:
(a) basic economic loss sustained on account of an accident occurring
within the United States of America, its possessions or territories, or
Canada, which is not recovered or recoverable under a policy issued in
satisfaction of the requirements of article 6 or 8 of the New York
Vehicle and Traffic law and article 51 of the New York Insurance Law;
(b) the difference between
(i) basic economic loss; and
(ii) basic economic loss recomputed in accordance with the time and
dollar limits [set out in the declarations];
14
and
[(c) an additional death benefit in the amount set out in the declarations]
15
14
Companies may substitute the appropriate term, reference or language for the matter set
out in brackets.
15
Language in brackets may be deleted if additional death benefits are not offered.
28
Two or More Motor Vehicles Insured Under This Policy
The limit of liability under this [Endorsement]
14
applicable to injuries sustained
by an eligible injured person while occupying, or while a pedestrian through being
struck by, the insured motor vehicle shall be as stated [in the declarations]
14
for that
insured motor vehicle. The limit of liability for injuries covered by this [Endorsement]
16
and sustained by an eligible injured person while occupying, or while a pedestrian
through being struck by, a motor vehicle, other than the insured motor vehicle, shall
be the highest limit stated for this coverage in the declarations for any insured motor
vehicle under this policy.
Arbitration
In the event any person making a claim for additional first-party benefits and the
Company do not agree regarding any matter relating to the claim, such person shall
have the option of submitting such disagreement to arbitration pursuant to
procedures promulgated or approved by the Superintendent of Insurance.
Subrogation
In the event of any payment for extended economic loss, the Company is
subrogated to the extent of such payments to the rights of the person to whom, or
for whose benefit, such payments were made. Such person must execute and
deliver instruments and papers and do whatever else is necessary to secure such
rights. Such person shall do nothing to prejudice such rights.
Other Coverage; Nonduplication
The eligible injured person shall not recover duplicate benefits for the same
elements of loss covered by this [Endorsement]
17
or any other optional first-party
automobile or no-fault automobile insurance coverage.
If an eligible injured person is entitled to New York mandatory and additional
personal injury protection benefits under any other policy, and if such eligible injured
person is not entitled to New York mandatory personal injury protection benefits
under this policy, then the coverage provided under this Additional Personal Injury
Protection Endorsement (New York) shall be excess over such other New York
mandatory and additional personal injury protection benefits.
When coverage provided under this [Endorsement]
17
applies on an excess
basis, it shall apply only in the amount by which the total limit of liability of New York
mandatory and additional personal injury protection coverage available under this
policy exceeds the total limit of liability for any other applicable New York mandatory
and additional personal injury protection coverage.
16
Companies may substitute the appropriate term, reference or language for the matter set
out in brackets.
17
Companies may substitute the appropriate term, reference or language for the matter set
out in brackets.
29
Subject to the provisions of the preceding three paragraphs, if the eligible
injured person is entitled to benefits under any other optional first-party automobile
or no-fault automobile insurance for the same elements of loss covered by this
[Endorsement]
17
this Company shall be liable only for an amount equal to the
proportion that the total amount available under this [Endorsement]
17
bears to the
sum of the amounts available under this [Endorsement]
18
and such other optional
insurance, for the same element of loss.
65-1.4 Medical Expense Exclusion. The Exclusion of Medical Expense from
Mandatory Personal Injury Protection Endorsement (New York), set out below is
approved and promulgated for use in accordance with the provisions of section
5103(g) of the Insurance Law. This endorsement may be used as a separate
endorsement or appropriately added to the mandatory endorsement.
EXCLUSION OF MEDICAL EXPENSE FROM MANDATORY
PERSONAL INJURY PROTECTION ENDORSEMENT
(New York)
In consideration of a reduction in premium, it is agreed that:
If the Medical Expense element of Basic Economic Loss is identified as not
applicable [in the declarations]
18
the Company shall not be liable for any items of
such loss which would otherwise be covered under the Mandatory Personal Injury
Protection Endorsement (New York) with respect to the named insured or named
insured and any relative as specified [in the declarations]
18
Coverage for any such
medical expense element of basic economic loss provided to such named insured,
or such relative, by a company or corporation in accordance with the provisions of
section 5103(g) of the New York Insurance Law shall reduce the $50,000 aggregate
limit of liability for basic economic loss to such person under this policy. This
endorsement shall be effective during the term of this policy so long as the medical
expense coverage provided by such company or corporation remains in effect,
notwithstanding any provisions [in the declarations]
18
of this policy to the contrary,
and in the event this endorsement shall no longer be in effect the premium may be
adjusted accordingly.
65-1.5 Declarations Page Requirements for policies insuring a motor
vehicle. (a) The declarations page of each policy must specify the dollar amount of
basic economic loss coverage under the policy and, if the insured has purchased
OBEL coverage, OBEL coverage shall be separately identified on the declarations
page of the policy.
(b) If Additional PIP coverage is purchased by the policyholder, the declarations
page shall state:
(i) the basic economic loss limits (Mandatory PIP coverage and, if
purchased, OBEL coverage);
18
Companies may substitute the appropriate term, reference or language for the matter set
out in brackets.
30
(ii) the maximum amount payable under Additional PIP coverage; and
(iii) the aggregate amount payable as PIP benefits, including the
maximum amounts payable as work loss benefits, other expenses and
the death benefit.
65-1.6 Deductibles. Each insurance company which offers insurance policies to
satisfy the minimum requirements of article 51 shall offer the policy prescribed in this
Subpart with a family deductible of $200 and without any deductible. Each insurance
company may also offer the above policy with a family deductible of $100. Any family
deductible shall apply to the "named insured" and any "relative," as these terms are
defined in the Mandatory Personal Injury Protection Endorsement set forth in this
Subpart.
65-1.7 Deviations. Deviations from these endorsements prescribed by this
Subpart may be submitted for prior approval, but approval will not be granted for any
reduction in first-party benefits payable to eligible injured persons, or any changes in
form alone, or nonsubstantive or editorial deviations or minor deviations in first-party
benefits or other provisions.
65-1.8 Coverage for nonresident motorists driving in this State. (a) The
automobile liability insurance policies of every authorized insurer which are sold in
any other state or Canadian province shall be deemed to satisfy the financial
security requirements of article 6 or 8 of the New York Vehicle and Traffic Law, and
shall be deemed to provide for the payment of first-party benefits pursuant to section
5103 of the New York Insurance Law when the insured motor vehicle is used or
operated in this State.
(b) The automobile liability insurance policies which are sold in any other state
or Canadian province by an unauthorized insurer which is controlled by, or
controlling, or under common control of, an authorized insurer shall be deemed to
satisfy the financial security requirements of article 6 or 8 of the New York Vehicle
and Traffic Law, and shall be deemed to provide for the payment of first-party
benefits pursuant to section 5103 of the New York Insurance Law when the insured
motor vehicle is used or operated in this State.
(c) Any other unauthorized insurer may file with the Superintendent of
Insurance a statement that its automobile insurance policies sold in any other state
or Canadian province will be deemed to satisfy the financial security requirements of
article 6 or 8 of the New York Vehicle and Traffic Law, and will be deemed to provide
for the payment of first-party benefits pursuant to section 5103 of the New York
Insurance Law when the insured motor vehicle is used or operated in this State.
11 NYCRR 65-2
(Regulation 68-B)
Rights and Liabilities of Self-insurers
65-2.1 Rights and liabilities of self-insurers. Definitions: For the purpose
of this part, (a) a “self-insurer” is any person, firm, association or corporation that:
(1) maintains a form of financial security other than an owner’s
automobile insurance policy in satisfaction of article 6 or 8 of the New York
Vehicle and Traffic Law; or
(2) is subject to article 51 of the New York Insurance Law as provided
for in section 321 of the New York Vehicle and Traffic Law.
(b) “motorcycle” means a vehicle as defined in section 123 of the New York
Vehicle and Traffic Law, and which is required to carry financial security pursuant to
article 6, 8 or 48-A of the Vehicle and Traffic Law;
(c) “motor vehicle” means a motor vehicle, as defined in section 311 of the
New York Vehicle and Traffic Law, and also includes fire and police vehicles, but
shall not include any motor vehicle not required to carry financial security pursuant to
article 6, 8 or 48-A of the Vehicle and Traffic Law, or a motorcycle as defined above;
(d) “occupying” means in or upon or entering into or alighting from;
(e) “personal injury” means bodily injury, sickness or disease;
(f) “relative” means a spouse, child or other person related to the self-insurer
(who is a natural person), by blood, marriage or adoption (including a ward or foster
child), who regularly reside’s in the self-insurer’s household, including any such
person who regularly resides in the household but is temporarily residing elsewhere;
and
(g) “use or operation” of a motor vehicle or a motorcycle includes the loading or
unloading of such vehicle.
65-2.2 Obligations of self-insurers. (a) In accordance with the provisions of
article 51 of the New York Insurance Law and this Part, a self-insurer shall pay first-
party benefits to reimburse for basic economic loss sustained by an eligible injured
person on account of personal injuries caused by an accident arising out of the use
or operation of a motor vehicle within the United States of America, its territories or
possessions, or Canada.
(b) First-party benefits. First-party benefits, other than death benefits, are
payments equal to basic economic loss, reduced by the following:
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(1) 20 percent of the eligible injured person’s loss of earnings from
work to the extent that an eligible injured person’s basic economic loss
consists of such loss of earnings; and
(2) amounts recovered or recoverable on account of personal injury to
an eligible injured person under State or Federal laws providing social
security disability or workers’ compensation benefits, or disability benefits
under article 9 of the New York Workers’ Compensation Law.
(c) Basic economic loss. Basic economic loss shall consist of medical expense,
work loss, other expense and, when death occurs, a death benefit as provided in this
section. Except for such death benefit, basic economic loss shall not include any
loss sustained on account of death. Basic economic loss of each eligible injured
person on account of any single accident shall not exceed $50,000, or $75,000 if the
self-insurer elects to provide optional basic economic loss coverage, except that any
death benefit shall be in addition thereto.
(d) If the self-insurer has elected to provide Optional Basic Economic Loss
(OBEL) coverage, the eligible injured person or that person’s legal representative
may specify that the OBEL coverage will be applied to one of the following four
options:
(1) basic economic loss;
(2) loss of earnings from work;
(3) psychiatric, physical or occupational therapy and rehabilitation; or
(4) a combination of options (2) and (3).
(e) OBEL coverage shall apply after the initial $50,000 of basic economic loss
has been exhausted.
(f) Medical expense. Medical expense shall consist of necessary expenses for:
(1) medical, hospital, surgical, nursing, dental, ambulance, X-ray,
prescription drug and prosthetic services;
(2) psychiatric, physical and occupational therapy and rehabilitation;
(3) any nonmedical remedial care and treatment rendered in
accordance with a religious method of healing recognized by the laws of
New York; and
(4) any other professional health services.
These medical expenses will not be subject to a time limitation, provided that
within one year after the date of the accident it is ascertainable that further medical
expenses may be sustained as a result of the injury. Payments pursuant to this
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section for necessary medical expenses shall be subject to the limitations and
requirements of section 5108 of the New York Insurance Law.
(g) Work loss. Work loss shall consist of the sum of the following losses and
expenses, up to a maximum payment of $2,000 per month for a maximum period of
three years from the date of the accident:
(1) loss of earnings from work which the eligible injured person would
have performed had such person not been injured, except that an
employee who is entitled to receive monetary payments, pursuant to
statute or contract with the employer, or who receives voluntary monetary
benefits paid for by the employer, by reason of such employee’s inability to
work because of personal injury arising out of the use or operation of a
motor vehicle, shall not be entitled to receive first-party benefits for loss of
earnings from work to the extent that such monetary payments or benefits
from the employer do not result in the employee suffering a reduction in
income or a reduction in such employee’s level of future benefits arising
from a subsequent illness or injury; and
(2) reasonable and necessary expenses sustained by the eligible
injured person in obtaining services in lieu of those which such person
would have performed for income.
(h) Other expenses. Other expenses shall consist of all reasonable and
necessary expenses, other than medical expense and work loss, up to $25 per day
for a period of one year from the date of accident causing injury.
(i) Death benefit. Upon the death of any eligible injured person, caused by an
accident for which the self-insurer is required to provide first-party benefits pursuant
to this section, the self-insurer will pay to the estate of such person a death benefit
of $2,000.
(j) Eligible injured person. Subject to the exclusions and conditions set forth
below, an eligible injured person is:
(1) the self-insurer (who is a natural person) and any relative who
sustains personal injury arising out of the use or operation of any motor
vehicle;
(2) the self-insurer (who is a natural person) and any relative who, on
or after July 22, 1982, sustains personal injury arising out of the use or
operation of any motorcycle while not occupying a motorcycle;
(3) any other person who sustains personal injury arising out of the
use or operation of the self-insured motor vehicle in the State of New York
while not occupying another motor vehicle; or
(4) any New York State resident who, on or after January 1, 1983,
sustains personal injury arising out of the use or operation of the
4
self-insured motor vehicle outside of New York State while not occupying
another motor vehicle.
65-2.3 Exclusions. The requirement for payment by a self-insurer of first-
party benefits does not apply to personal injury sustained by:
(a) the self-insurer (who is a natural person) or relative while occupying, or
while a pedestrian through being struck by, any motor vehicle owned by the self-
insurer with respect to which the coverage required by the New York Comprehensive
Motor Vehicle Insurance Reparations Act is not in effect;
(b) any relative while occupying, or while a pedestrian through being stuck by,
any motor vehicle owned by the relative with respect to which the coverage required
by the New York Comprehensive Motor Vehicle Insurance Reparations Act is not in
effect;
(c) the self-insurer (who is a natural person) or relative while occupying, or
while a pedestrian through being struck by, a motor vehicle in New York State, other
than the self-insured motor vehicle, with respect to which the coverage required by
the New York Comprehensive Motor Vehicle Insurance Reparations Act is in effect;
(d) the self-insurer (who is a natural person) or relative while not occupying a
motor vehicle or a motorcycle when stuck by a motorcycle in New York State with
respect to which the coverage required by the New York Comprehensive Motor
Vehicle Insurance Reparations Act is in effect;
(e) any New York State resident other than the self-insurer or relative injured
through the use or operation of the self-insured motor vehicle outside of New York
State if such resident is the owner or a relative of the owner of a motor vehicle
insured under another policy providing the coverage required by the New York
Comprehensive Motor Vehicle Insurance Reparations Act;
(f) any New York State resident other than the self-insurer or relative injured
through the use or operation of the self-insured motor vehicle outside of New York
State if such resident is the owner of a motor vehicle for which the coverage
required by the New York Comprehensive Motor Vehicle Insurance Reparations Act
is not in effect;
(g) any person in New York State while occupying the self-insured motor
vehicle which is a bus or school bus, as defined in sections 104 and 142 of the New
York Vehicle and Traffic Law, but only if such person is a named insured or relative
under any policy providing the coverage required by the New York Comprehensive
Motor Vehicle Insurance Reparations Act; however, this exclusion does not apply to
the operator, an owner, or an employee of the owner or operator, of such bus or
school bus;
(h) any person while occupying a motorcycle;
(i) any person who intentionally causes his own personal injury;
5
(j) any person as a result of operating a motor vehicle while in an intoxicated
condition or while his ability to operate such vehicle is impaired by the use of a drug
(within the meaning of section 1192 of the New York Vehicle and Traffic Law); or
(k) any person while:
(1) committing an act which would constitute a felony, or seeking to
avoid lawful apprehension or arrest by a law enforcement officer;
(2) operating a motor vehicle in a race or speed test;
(3) operating or occupying a motor vehicle known to him to be stolen;
or
(4) repairing, servicing or otherwise maintaining a motor vehicle if
such conduct is within the course of a business of repairing, servicing or
otherwise maintaining a motor vehicle and the injury occurs on the
business premises.
65-2.4 Conditions. (a) Action against self insurer. No action shall lie against
the self-insurer unless, as a condition precedent thereto, there shall have been full
compliance with the terms of this section.
(b) Notice. In the event of an accident, written notice setting forth details
sufficient to identify the eligible injured person, along with reasonably obtainable
information regarding the time, place and circumstances of the accident, shall be
given by or on behalf of each eligible injured person to the self-insurer or any of the
self-insurer’s authorized agents, as soon as reasonably practicable, but in no event
more than 30 days after the date of the accident, unless the eligible injured person
submits written proof providing clear and reasonable justification for the failure to
comply with such time limitation. If an eligible injured person or that person’s legal
representative institutes a proceeding to recover damages for personal injury under
section 5104(b) of the New York Insurance Law, a copy of the summons and
complaint or other process served in connection with such action shall be forwarded
as soon as practicable to the self-insurer or any of the self-insurer’s authorized
agents by such eligible injured person or that person’s legal representative.
(c) Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the
case of a claim for health service expenses, the eligible injured person or that
person’s assignee or legal representative shall submit written proof of claim to the
self-insurer, including full particulars of the nature and extent of the injuries and
treatment received and contemplated, as soon as reasonably practicable but, in no
event later than 45 days after the date services are rendered. The eligible injured
person or that person’s legal representative shall submit written proof of claim for
work loss benefits and for other necessary expenses to the self-insurer as soon as
reasonably practicable but, in no event, later than 90 days after the work loss is
incurred or the other necessary services are rendered. The foregoing time limitations
for the submission of proof of claim shall apply unless the eligible injured person
submits written proof providing clear and reasonable justification for the failure to
6
comply with such time limitation. Upon request by the self-insurer, the eligible injured
person or that person’s assignee or representative shall:
(1) execute a written proof of claim under oath;
(2) as may reasonably be required submit to examinations under oath
by any person named by the self-insurer and subscribe the same;
(3) provide authorization that will enable the self-insurer to obtain
medical records; and
(4) provide any other pertinent information that may assist the self-
insurer in determining the amount due and payable.
The eligible injured person shall submit to medical examination by physicians
selected by, or acceptable to, the self-insurer, when, and as often as, the self-insurer
may reasonably require.
(d) Arbitration. In the event any person making a claim for first-party benefits
and the self-insurer do not agree regarding any matter relating to the claim, such
person shall have the option of submitting such disagreement to arbitration pursuant
to subpart 64-5 of this Part.
65-2.5 Reimbursement and trust agreement. (a) To the extent that the self-
insurer pays first-party benefits, the self-insurer is entitled to the proceeds of any
settlement or judgment resulting from the exercise of any right of recovery for
damages for personal injury under section 5104(b) of the New York Insurance Law.
The self-insurer shall have a lien upon any such settlement or judgment to the extent
that the self-insurer has paid first-party benefits. An eligible injured person shall:
(1) hold in trust, for the benefit of the self-insurer, all rights of recovery
which he shall have for personal injury under section 5104(b) of the New
York Insurance Law;
(2) do whatever is proper to secure, and shall do nothing to prejudice,
such rights; and
(3) execute, and deliver to the self-insurer, instruments and papers as
may be appropriate to secure the rights and obligations of such person and
the self-insurer, established by this Part.
(b) An eligible injured person shall not compromise an action to recover
damages brought under section 5104(b) of the New York Insurance Law except:
(1) with the written consent of the self-insurer; or
(2) with approval of the court; or
(3) where the amount of the settlement exceeds $50,000.
7
65-2.6 Other sources of first-party benefits. (a) Where more than one
source of first-party benefits required by article 51 of the New York Insurance Law
and article 6 or 8 of the New York Vehicle and Traffic Law is available and applicable
to an eligible injured person in any one accident, the self-insurer is liable to an
eligible injured person only for an amount equal to the maximum amount that the
eligible injured person is entitled to recover from the self-insurer, divided by the
number of available and applicable sources of required first-party benefits.
(b) An eligible injured person shall not recover duplicate benefits for the same
elements of loss required to be covered by the self-insurer or any mandatory first-
party automobile or no-fault automobile insurance coverage issued in compliance
with the laws of another state. If the eligible injured person is entitled to benefits
under any such mandatory first-party automobile or no-fault automobile insurance for
the same elements of loss required to be covered by the self-insurer, the self-insurer
shall be liable only for an amount equal to the proportion that the total amount
available from the self-insurer bears to the sum of the amount available from the
self-insurer and the amount available under such mandatory insurance for the
common elements of loss. However, where another state’s mandatory first-party or
no-fault automobile insurance law provides unlimited coverage available to an
eligible injured person for an element of loss required to be covered by the self-
insurer, the obligation of the self-insurer is to share equally for that element of loss
with such other mandatory insurance until the $50,000, or $75,000 if provided, limit
available from the self-insurer is exhausted by the payment of that element of loss
and any other elements of loss.
11 NYCRR 65-3
(Regulation 68-C)
Claims for Personal Injury Protection Benefits
65-3.1 Applicability. The following are rules for the settlement of claims for
first-party and additional first-party benefits on account of injuries arising out of the
use or operation of a motor vehicle, a motorcycle or an all-terrain vehicle. These
rules shall apply to insurers and self-insurers, and the term insurer, as used in this
section, shall include both insurers and self-insurers as those terms are defined in
this Part and article 51 of the Insurance Law, the Motor Vehicle Accident
Indemnification Corporation (MVAIC), pursuant to section 5221(b) of the Insurance
Law and any company or corporation providing insurance pursuant to section
5103(g) of the Insurance Law, for the items of basic economic loss specified in
section 5102(a) of the Insurance Law.
65-3.2 Claim practice principles to be followed by all insurers. (a) Have
as your basic goal the prompt and fair payment to all automobile accident victims.
(b) Assist the applicant in the processing of a claim. Do not treat the applicant
as an adversary.
(c) Do not demand verification of facts unless there are good reasons to do so.
When verification of facts is necessary, it should be done as expeditiously as
possible.
(d) Hasten the processing of a claim through the use of a telephone whenever
it is possible to do so.
(e) Clearly inform the applicant of the insurer’s position regarding any disputed
matter.
(f) Respond promptly, when a response is indicated, to all communications
from insureds, applicants, attorneys and any other interested persons.
(g) Every insurer shall distribute copies of this regulation to every person
directly responsible to it for the handling and settlement of claims for first-party
benefits, and every insurer shall satisfy itself that all such personnel are thoroughly
conversant with this regulation.
65-3.3 Notice. (a) If the applicant’s written notice of a claim, required by
section 65-2.4 of this Part and the mandatory and additional personal injury
protection endorsements, is given to a designated agent of an insurer or to a person
authorized to receive service of summons, the insurer is deemed to have received
the notice; provided, however, that unless otherwise provided by law or contract,
notice to the agent shall not be notice to the insurer if the agent promptly notifies the
applicant that the agent is not authorized to receive notice of a claim.
(b) If the agent is permitted to receive a notice of a claim, the agent may
acknowledge receipt of such notice in the manner set forth in this section.
2
(c) Receipt of a Department of Motor Vehicles Accident Report 104 (MV 104),
or other accident report indicating injuries to eligible injured persons, shall be
deemed written notice of a claim.
(d) The written notice required by section 65-2.4 of this Part and the mandatory
and additional personal injury protection endorsement(s) shall be deemed to be
satisfied by the insurer’s receipt of a completed prescribed application for motor
vehicle no-fault benefits (NYS Form N-F 2) forwarded to the applicant pursuant to
subdivision 65-3.4(b) of this subpart or by the insurer’s receipt of a completed
hospital facility form (NYS Form N-F 5).
(e) When an insurer denies a claim based upon the failure to provide timely
written notice of claim or timely submission of proof of claim by the applicant, such
denial must advise the applicant that late notice will be excused where the applicant
can provide reasonable justification of the failure to give timely notice.
65-3.4 Acknowledgment of claim. (a) Whenever the insurer receives notice
of claim by telephone, the party receiving such notice on behalf of the insurer shall
be identified to the caller by name and title and shall request the name, address and
telephone number of the applicant and the name of the policyholder or the policy
number or both, if available, along with reasonably obtainable information regarding
the time, place and circumstances of the accident which will enable the insurer to
begin processing the claim.
(b) Unless the insurer will pay the claim as submitted within 30 calendar days,
then, within five business days after notice is received by the insurer at the address
of its proper claim processing office, either orally pursuant to subdivision (a) of this
section or in any other manner, the insurer shall forward to the applicant the
prescribed application for motor vehicle no-fault benefits (NYS Form N-F 2)
accompanied by the prescribed cover letter (NYS Form N-F 1). If notice is initially
received by the insurer at an address other than the proper claims processing office,
the five -day period for forwarding of the prescribed forms shall commence on the
day such notice is received at the proper claims processing office, but in no event
shall the prescribed forms be forwarded later than ten business days after receipt of
the original notice.
(c) Attached is an appendix (Appendix 13, infra), which includes the following
prescribed claim forms that must be used by all insurers, and shall not be altered
unless approved by the superintendent:
(1) Cover Letter (NYS Form N-F 1A) – to be used with policies effective on
or after September 1, 2001;
(2) Cover Letter (NYS Form N-F 1B) – to be used with policies effective
prior to September 1, 2001;
(3) Application for Motor Vehicle No-Fault Benefits (NYS Form N-F 2);
3
(4) Verification of Treatment by Attending Physician or Other Provider
of Health Service (NYS Form N-F 3);
(5) Verification of Hospital Treatment (NYS Form N-F 4);
(6) Hospital Facility Form (NYS Form N-F 5);
(7) Employer’s Wage Verification Report (NYS Form N-F 6);
(8) Verification of Self-Employment Income (NYS Form N-F 7);
(9) Agreement to Pursue Social Security Disability Benefits
(NYS Form N-F 8);
(10) Agreement to Pursue Workers’ Compensation or New York State
Disability Benefits (NYS Form N-F 9);
(11) Denial of Claim Form (NYS Form N-F 10);
(12) Subrogation Agreement (NYS Form N-F 11);
(13) Lump-Sum Settlement Agreement (NYS Form N-F 12);
(14) Election-Optional Basic Economic Loss (NYS Form N-F 13);
65-3.5 Claim procedure. (a) Within 10 business days after receipt of the
completed application for motor vehicle no-fault benefits (NYS Form N-F 2) or other
substantially equivalent written notice, the insurer shall forward, to the parties
required to complete them, those prescribed verification forms it will require prior to
payment of the initial claim.
(b) Subsequent to the receipt of one or more of the completed verification
forms, any additional verification required by the insurer to establish proof of claim
shall be requested within 15 business days of receipt of the prescribed verification
forms.
(c) The insurer is entitled to receive all items necessary to verify the claim
directly from the parties from whom such verification was requested.
(d) If the additional verification required by the insurer is an examination under
oath or a medical examination, the insurer shall schedule the examination to be held
within 30 calendar days from the date of receipt of the prescribed verification forms.
(e) All examinations under oath and medical examinations requested by the
insurer shall be held at a place and time reasonably convenient to the applicant and
medical examinations shall be conducted in a facility properly equipped for the
performance of the medical examination. The insurer shall inform the applicant at
the time the examination is scheduled that the applicant will be reimbursed for any
loss of earnings and reasonable transportation expenses incurred in complying with
4
the request. When an insurer requires an examination under oath of an applicant as
additional verification to establish proof of claim, such requirement must be based
upon the application of objective standards so that there is specific objective
justification supporting the use of such examination. Insurer standards shall be
available for review by Department examiners.
(f) An insurer must accept proof of claim submitted on a form other than a
prescribed form if it contains substantially the same information as the prescribed
form. An insurer, however, may require the submission of the prescribed application
for motor vehicle no-fault benefits, the prescribed verification of treatment by
attending physician or other provider of health service, and the prescribed hospital
facility form.
(g) In lieu of a prescribed application for motor vehicle no-fault benefits
submitted by an applicant and a verification of hospital treatment (NYS Form N-F 4),
an insurer shall accept a completed hospital facility form (NYS Form N-F 5) (or an N-
F 5 and Uniform Billing Form (UBF-1) which together supply all the information
requested by the N-F 5) submitted by a provider of health services with respect to
the claim of such provider.
(h) When benefits are claimed under an additional personal injury protection
endorsement, the insurer may require that the applicant execute a prescribed
subrogation agreement (NYS Form N-F 11) prior to the payment of any benefits. If
the insurer shall impose the above requirement, it shall deliver the prescribed
agreement to the applicant as soon as it is known that the claim is payable under an
additional personal injury protection endorsement.
(i) If the insurer has knowledge that the applicant for benefits under a
mandatory or additional personal injury protection endorsement is entitled to benefits
under any other mandatory or optional first-party automobile or no-fault automobile
insurance for the same elements of loss, the insurer should give written notice of
claim to all other such sources of benefits in order to protect its right under the
endorsement to recover from such other sources their proportionate share of the
costs of the claim and the allocated expenses of processing the claim.
(j) Every insurer who does not staff and maintain a claims office in this state
shall establish a communications system, by means of a direct toll-free telephone
line, to conveniently process all claims made pursuant to article 51 of the Insurance
Law. Such toll-free number shall appear on all correspondence relating to claims.
(k) Every insurer, which writes more than 1,000 motor vehicle liability policies in
this state, shall establish procedures for the receipt of all claims, notices and
verification, subject to this Part, by facsimile and/or electronic data transmittal.
(l) The insurer shall establish standards for review of its determinations that
applicants have provided late notice of claim or late proof of claim. In the case of
notice of claim, such standards shall include, but not be limited to, appropriate
consideration for pedestrians and non-related occupants of motor vehicles who may
have difficulty ascertaining the identity of the insurer. In the case of proof of claim,
such standards shall include, but not be limited to, appropriate consideration for
5
emergency care providers, demonstrated difficulty in ascertaining the identity of the
insurer and inadvertent submission to the incorrect insurer. The insurer shall
establish procedures, based upon objective criteria, to ensure due consideration of
denial of claims based upon late notice or late submission of proof of claim,
including supervisory review of all such determinations. Insurer standards shall be
available for review by Department examiners.
(m) The failure of an employer, or other third party, to provide information
necessary to establish proof of claim for lost wages on behalf of an applicant shall
not be utilized as a basis for denial of claim based upon late submission of proof of
claim.
(n) The timely submission of a proof of claim by a hospital that is based upon
Diagnostic Related Group (DRG) codes which may be adjusted prospectively shall
be deemed to be timely notice for the submission of a subsequent claim which is
adjusted in accordance with the promulgaiton of DRG codes which were not
implemented at the time of the original submission of claim.
65-3.6 Follow-up requirements. (a) Application for motor vehicle no-fault
benefits. At a minimum, the insurer shall, within 10 calendar days, mail a second
application for motor vehicle no-fault benefits, with the prescribed cover letter, to the
eligible injured person or such person’s attorney if, 30 calendar days after the
original mailing, a prescribed application has not been completed and returned to the
insurer. If the follow-up is sent to the applicant’s attorney, a copy of the prescribed
cover letter, marked “second notice”, shall be forwarded to the applicant.
(b) Verification requests. At a minimum, if any requested verifications has not
been supplied to the insurer 30 calendar days after the original request, the insurer
shall, within 10 calendar days, follow up with the party from whom the verification
was requested, either by telephone call, properly documented in the file, or by mail.
At the same time the insurer shall inform the applicant and such person’s attorney of
the reason(s) why the claim is delayed by identifying in writing the missing
verification and the party from whom it was requested.
65-3.7 Election. (a) If an insured has purchased optional basic economic loss
(OBEL) coverage pursuant to Section 5102(a)(5) of the Insurance Law, the insurer
shall notify each eligible injured person (or that person’s legal representative)
making a claim under such policy that such person may elect how OBEL coverage
will be applied.
(b) The insurer shall mail form NYS N-F 13 to the eligible injured person or that
person’s legal representative as soon as, and in no event later than 15 calendar
days after, the insurer has received claims aggregating $30,000 in basic economic
loss.
(c) If the eligible injured person or that person’s legal representative does not
return the election form (NYS N-F 13) within 15 calendar days after the initial
mailing, then within 5 calendar days after such time has elapsed the insurer shall
mail to the eligible injured person or that person’s legal representative a second
election notice, clearly marked “SECOND NOTICE”.
6
(d) Failure of the eligible injured person or that person’s legal representative to
respond to the second notice within 15 calendar days after its mailing shall be
considered an election by the eligible injured person to apply OBEL coverage to all
elements of basic economic loss.
(e) Once made by the eligible injured person or that person’s legal
representative, an OBEL election cannot be changed, except that, if claims payable
under OBEL coverage have not yet been received by the Company, an eligible
injured person who has failed to respond to the second notice in a timely manner
may make an election.
65-3.8 Payment or denial of claim (30 day rule).
(a) (1) No-Fault benefits are overdue if not paid within 30 calendar days after
the insurer receives proof of claim, which shall include verification of all of
the relevant information requested pursuant to section 65-3.5 of this
subpart. In the case of an examination under oath or a medical examination,
the verification is deemed to have been received by the insurer on the day
the examination was performed.
(2) An insurer shall defer payment of OBEL benefits for claims submitted
by or on behalf of the eligible injured person until an OBEL option has been
elected in accordance with section 65-3.7 of this subpart. An insurer shall
pay or deny such claims under OBEL coverage within 30 calendar days of
the date that an election has been made.
(b) (1) An insurer may not interrupt the payment of benefits for any element of
basic or extended economic loss pending the administering of a medical
examination, unless the applicant or the applicant’s attorney is responsible
for the delay or inability to schedule the examination, in which case any
denial of payment shall be made only in accordance with policy provisions
on a prescribed denial of claim form (NYS Form N-F 10).
(2) Notwithstanding paragraph (1) of this subdivision, if the insurer has
information which clearly demonstrates that the applicant is no longer
disabled, the insurer may discontinue the payment of benefits by forwarding
to the applicant a prescribed denial of claim form.
(3) Except as provided in subdivision (e) of this section, an insurer shall
not issue a denial of claim form (NYS Form N-F 10) prior to its receipt of
verification of all of the relevant information requested pursuant to section
65-3.5 of this subpart (e.g., medical reports, wage verification, etc.).
(4) If the specific reason for a denial of a no-fault claim, or any element
thereof, is a medical examination or peer review report requested by the
insurer, the insurer shall release a copy of that report to the applicant for
benefits, the applicant’s attorney, or the applicant’s treating physician, upon
the written request of any of these parties.
7
(c) Within 30 calendar days after proof of claim is received, the insurer shall
either pay or deny the claim in whole or in part.
(1) If the insurer denies a claim in whole or in part involving elements
of basic economic loss or extended economic loss, the insurer shall notify
the applicant or the authorized representative on the prescribed denial of
claim form, in duplicate, and shall furnish, if requested by the applicant, one
copy of all prescribed claim forms submitted by or on behalf of the
applicant thereto. However, where a denial involves a portion of a health
provider’s bill, the insurer may make such a denial on a form or letter
approved by the department which is issued in duplicate. No form or letter
shall be approved unless it contains substantially the same information as
the prescribed form which is relevant to the claim denied.
(2) Notwithstanding paragraph (1) of this subdivision, where there is a
denial in part of a medical bill as a result of charges not conforming to
section 5108 of the Insurance Law, an insurer may effect compliance with
paragraph (1) for those overcharges of $50 or less by telephone agreement
with the provider or provider’s representative, with proper documentation of
such agreement in the claim file. The provider must have been entitled to
direct payment pursuant to section 65-3.12 of this subpart.
(d) Where an insurer denies part of a claim, it shall pay benefits for the
undisputed elements of the claim. Such payments shall be made without prejudice to
either party.
(e) If an insurer has determined that benefits are not payable for any of the
following reasons:
(1) no coverage on the date of accident;
(2) circumstances of the accident not covered by no-fault; or
(3) statutory exclusions pursuant to section 5103(b) of the Insurance Law;
it shall notify the applicant within 10 business days after such determination
on a prescribed denial of claim form, specifying the reasons for the denial.
Failure by an insurer to notify the applicant of its denial of the claim within
the 10-business-day period after its determination shall not preclude the
insurer from asserting a defense to the claim which is based upon the
reasons for such denial.
(f) An insurer shall be entitled to receive proper proof of claim and a
failure to
observe any of the time frames specified in this section shall not prevent an insurer
from requiring proper proof of claim.
(g) Notwithstanding subdivision (e) of this section, if an insurer has reason to
believe that the applicant was operating a motor vehicle while intoxicated or impaired
by the use of a drug, and such intoxication or impairment was a contributing cause
of the automobile accident, the insurer shall be entitled to all available information
relating to the applicant’s condition at the time of the accident. Proof of a claim shall
8
not be complete until the information which has been requested, pursuant to
subdivision 65-3.5 (a) or (b) of this subpart, has been furnished to the insurer by the
applicant or the authorized representative.
(h) Where the insurer has determined that a self-employed applicant’s disability
arose from the claimed accident, the insurer shall be deemed to have proof of claim
for loss of earnings or substitute services, subject to receipt of medical proof of
disability for the period claimed, when it has received a completed prescribed
verification of self-employment income form (NYS N-F 7) and the proof requested
thereon. The insurer shall determine therefrom the amount of loss of earnings
benefits, if any, due the applicant. Notwithstanding the above, if an insurer requires
verification in addition to the proof supplied, it may request such additional
verification pursuant to subdivision 65-3.5 (b) of this subpart.
(i) A death benefit claim will be deemed to have been proven when the insurer
receives a copy of the decedent’s death certificate and proof that the personal
representative of the decedent’s estate was duly appointed in this State or any other
jurisdiction.
(j) For the purposes of counting the 30 calendar days after proof of claim,
wherein the claim becomes overdue pursuant to section 5106 of the Insurance Law,
with the exception of section 65-3.6 of this subpart, any deviation from the rules set
out in this section shall reduce the 30 calendar days allowed.
Example: Where an insurer sends an application for motor vehicle no-fault
benefits 15 business days after notice is received at the address of the insurer’s
proper claim processing office instead of five business days, the 30 calendar days
permitted by subdivision (a) of this section are reduced to 20 calendar days.
65-3.9 Interest on overdue payments. (a) All overdue mandatory and
additional personal injury protection benefits due an applicant or assignee shall bear
interest at a rate of two percent per month, calculated on a pro rata basis using a 30-
day month. When payment is made on an overdue claim, any interest calculated to
be due in an amount exceeding $5 shall be paid to the applicant or the applicant’s
assignee without demand therefor.
(b) The insurer shall not suggest or require, as a condition to settlement of a
claim, that the interest due be waived.
(c) If an applicant does not request arbitration or institute a lawsuit within 30
days after the receipt of a denial of claim form or payment of benefits calculated
pursuant to Insurance Department regulations, interest shall not accumulate on the
disputed claim or element of claim until such action is taken. If any applicant is a
member of a class in a class action brought for payment of benefits, but is not a
named party, interest shall not accumulate on the disputed claim or element of claim
until a class which includes such applicant is certified by court order, or such
benefits are authorized in that action by Appellate Court decision, whichever is
earlier.
9
(d) If an applicant has submitted a dispute to arbitration or the courts, interest
shall accumulate, unless the applicant unreasonably delays the arbitration or court
proceeding.
(e) The insurer shall separately identify any interest payment on an overdue
claim from benefit payments. This may be done by issuing separate drafts for each
amount or by an accompanying statement that clearly and separately identifies the
components of the draft.
(f) An insurer may not include in its ratemaking calculations any interest paid
on an overdue claim.
65-3.10 Attorneys. (a) An applicant or an assignee shall be entitled to recover
their attorney’s fees, for services necessarily performed in connection with securing
payment, if a valid claim or portion thereof was denied or overdue. If such a claim
was initially denied and subsequently paid by the insurer, the attorney’s fee shall be
$80. If such a claim was overdue but not denied, the attorney’s fee shall be equal to
20 percent of the amount of the first-party benefits and any additional first-party
benefits plus interest payable pursuant to section 65-3.10 of this subpart, subject to
a maximum fee of $60.
(b) If a dispute is resolved in accordance with any of the optional arbitration
procedures contained in this Part, either during the initial review by the Insurance
Department or by an arbitration award, and if payment is not made by the insurer in
accordance with the terms specified in the conciliation letter or arbitration award
within 45 days following such resolution, an additional attorney’s fee shall be paid by
the insurer when the attorney writes to the insurer in order to receive such overdue
payment. The additional attorney’s fee shall be $60 and shall become payable only
after written request from the attorney to the insurer, received by the insurer more
than 45 days after mailing of the conciliation letter or arbitration award. Such fee
shall not be payable if payment was made by the insurer prior to the attorney’s
request for such payment or if an arbitration award is appealed in accordance with
the provisions of this Part.
(c) The insurer shall segregate any attorney’s fee on an overdue claim from the
loss and interest payments, either through issuance of separate drafts or through an
accompanying statement which clearly and separately identifies the components of
the draft.
(d) No attorney’s fee payable by an insurer on account of an overdue claim
may be included by the insurer in any rate making calculations.
65-3.11 Direct payments. (a) An insurer shall pay benefits for any element of
loss, other than death benefits, directly to the applicant or, when appropriate, to the
applicant’s parent or legal guardian or to any person legally responsible for
necessities, or, upon assignment by the applicant or any of the aforementioned
persons, shall pay benefits directly to providers of health care services as covered
under section five thousand one hundred two (a)(1) of the Insurance Law, or to the
applicant’s employer for loss of earnings from work as authorized under section five
10
thousand one hundred two(a)(2) of the Insurance Law. Death benefits shall be paid
to the estate of the eligible injured person.
(b) If an assignment has been furnished an insurer, the assignor or legal
representative of the assignor shall not unilaterally revoke the assignment after the
services for which the assignment was originally executed were rendered. If the
assignment is revoked for services not yet rendered, the assignor or legal
representative shall provide written notification to the insurer that the assignee has
been notified of the revocation.
(c) The draft or check in payment of benefits shall include information sufficient
to identify the element(s) of covered expense(s) being reimbursed, or must be
accompanied by an explanation containing such identifying information.
Example: Payment of loss of earnings shall indicate that the payment is for loss
of earnings, and shall identify the period of lost time from work being reimbursed and
the rate at which reimbursement is being made.
65-3.12 Sources of mandatory personal injury protection benefits. (a)
Institution of claims for first-party benefits-priority.
(1) Subject to paragraph (9) of this subdivision, an applicant who is an
operator or occupant of an insured motor vehicle, or any other person, not
occupying another motor vehicle or a motorcycle, who sustains a personal
injury arising out of the use or operation in New York State of such motor
vehicle, shall institute the claim against the insurer of such motor vehicle.
(2) An applicant who is neither an operator nor an occupant of a motor
vehicle or a motorcycle, and who sustains a personal injury arising out of
the use or operation in New York State of more than one insured motor
vehicle or insured motorcycle shall institute the claim against the insurer of
any one of such motor vehicles or motorcycles unless the insurers agree
among themselves that one of them will accept and pay the claim initially.
(3) An applicant who is a named insured or a relative of a named
insured, other than the occupant of a motorcycle, and who sustains a
personal injury arising out of the use or operation of a motor vehicle outside
of New York State, shall institute the claim against the insurer of the named
insured or the insurer of the relative. Where there is more than one insurer
which would be the source of benefits, the insurers may agree among
themselves, if there is a valid basis therefor, that one of them will accept
and pay the claim initially. If there is no such agreement, the provisions of
subdivisions (b) and (e) of this section shall apply.
(4) An applicant who is a named insured or a relative of a named
insured, other than the occupant of a motorcycle, and who sustains a
personal injury arising out of the use or operation of an uninsured motor
vehicle in New York State, shall institute the claim against the insurer of the
named insured or the insurer of the relative. Where there is more than one
insurer which would be the source of benefits, the insurers may agree
11
among themselves, if there is a valid basis therefor, that one of them will
accept and pay the claim initially. If there is no such agreement, the
provisions of subdivisions (b) and (e) of this section shall apply. If there is
no such insurer and the accident occurs in New York State, then an
applicant who is a qualified person as defined in article 52 of the Insurance
Law shall institute the claim against the MVAIC.
(5) An applicant who is neither an operator nor an occupant of a motor
vehicle or a motorcycle, and who sustains a personal injury arising out of
the use or operation in New York State of an insured motorcycle, shall
institute the claim against the insurer of the motorcycle.
(6) An applicant who is a named insured or a relative of a named
insured, other than the occupant of a motor vehicle or a motorcycle, and
who sustains a personal injury arising out of the use or operation of an
uninsured motorcycle in New York State shall institute the claim against the
insurer of the named insured or the insurer of the relative. Where there is
more than one insurer which would be the source of benefits, the insurers
may agree among themselves, if there is a valid basis therefor, that one of
them will accept and pay the claim initially. If there is no such agreement,
the provisions of subdivisions (b) and (e) of this section shall apply. If there
is no such insurer and the accident occurs in New York State, then an
applicant who is a qualified person as defined in article 52 of the Insurance
Law shall institute the claim against the MVAIC.
(7) An applicant who is a named insured or a relative of a named
insured, other than the occupant of a motor vehicle or a motorcycle, and
who sustains a personal injury arising out of the use or operation of a
motorcycle outside of New York State shall institute the claim against the
insurer of the named insured or relative. Where there is more than one
insurer which would be the source of benefits, the insurers may agree
among themselves, if there is a valid basis therefor, that one of them will
accept and pay the claim initially. If there is no such agreement, the
provisions of subdivisions (b) and (e) of this section shall apply.
(8) An applicant who is a New York State resident and who is neither a
named insured or relative under any mandatory personal injury protection
endorsement nor the owner of an uninsured motor vehicle and who
sustains a personal injury arising out of the use or operation of a New York
insured motor vehicle outside of New York State shall institute the claim
against the insurer of such motor vehicle.
(9) An applicant, other than an operator, owner, or employee of the
owner or operator of a bus or school bus, who, while an occupant of such
bus or school bus, sustains a personal injury arising out of the use or
operation in New York State of such bus or school bus, shall institute the
claim against the applicant’s own insurer. If the applicant does not have an
insurer, the applicant shall institute the claim against the insurer of the bus
or school bus.
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(10) An applicant who is an operator, owner, or employee of the
operator or owner of a bus or school bus, and who, while an occupant of
such bus or school bus, sustains a personal injury arising out of the use or
operation of such bus or school bus, shall institute the claim against the
insurer of such bus or school bus.
(b) If a dispute regarding priority of payment arises among insurers who
otherwise are liable for the payment of first-party benefits, then the first insurer to
whom notice of claim is given pursuant to section 65-3.3 or subdivision 65-3.4 (a) of
this subpart, by or on behalf of an eligible injured person, shall be responsible for
payment to such person. Any such dispute shall be resolved in accordance with the
arbitration procedures established pursuant to section 5105 of the Insurance Law
and section 65-4.11 of this Part.
(c) If the source of first-party benefits is at issue because the status of the
injured person as a pedestrian or an occupant of a motor vehicle is in dispute, the
insurer to whom notice of claim was given or if such notice was given to more than
one insurer, the first insurer to whom notice was given shall, within 15 calendar days
after receipt of notice, obtain an agreement with the other insurer or insurers as to
which insurer will furnish no-fault benefits. If such an agreement is not reached
within the aforementioned 15 days, then the insurer to whom such notice was first
given shall process the claim and pay first-party benefits and resolve the dispute in
accordance with the arbitration procedures established pursuant to section 5105 of
the Insurance Law and section 65-4.11 of this Part.
(d) The insurer of the named insured or relative shall be responsible for the
payment of first-party benefits to such person when he/she is injured through the
use or operation of another motor vehicle, the alleged insurer of which has denied
coverage claiming it did not have a policy in force on such vehicle on the accident
date; provided, however, that the named insured or relative injured in the accident
was not the owner of the alleged uninsured motor vehicle. Payment by the insurer of
the named insured or relative shall not affect any legal right of such insurer to
challenge the validity of the denial by the other insurer.
(e) Any insurer paying first-party benefits shall be reimbursed by other insurers
for their proportionate share of the costs of the claim and the allocated expenses of
processing the claim, in accordance with the provisions entitled “Other coverage”
contained in section 65-1.1 of this Part and provisions entitled “Other sources of
first-party benefits” contained in subpart 65-2 of this Part.
65-3.13 Sources of additional personal injury protection benefits. (a)
Institution of claims-priority. Generally, an applicant’s initial source of additional
personal injury protection benefits will be the same source which provides the
mandatory personal injury protection benefits, until the total available limits under
that source’s mandatory and additional personal injury protection coverages are
exhausted. Specifically:
(1) An applicant who is an operator or occupant of an insured motor
vehicle covered for additional personal injury protection benefits, and who
sustains a personal injury arising out of the use or operation in New York
13
State of such motor vehicle, shall institute the claim against the insurer of
such motor vehicle.
(2) An applicant who is a named insured or a relative of a named
insured covered by additional personal injury protection benefits, and who,
while an operator or occupant of a motor vehicle, sustains a personal injury
arising out of the use or operation of such motor vehicle outside of New
York State, shall institute the claim against the insurer of the named
insured or the relative. Where there is more than one insurer which would
be the source of benefits, the first such insurer applied to shall process the
claim, unless the insurers agree among themselves that another such
insurer will accept and pay the claim initially. (See subdivision (b) of this
section.)
(3) An applicant who is a named insured or a relative of a named
insured covered for additional personal injury protection benefits, and who
is neither an operator nor an occupant of a motor vehicle or a motorcycle,
and who sustains a personal injury through the use or operation of a motor
vehicle or a motorcycle shall institute the claim against the insurer of the
named insured or the relative. Where there is more than one insurer which
would be the source of benefits, the first such insurer applied to shall
process the claim, unless the insurers agree among themselves that
another such insurer will accept and pay the claim initially. (See subdivision
(b) of this section.)
(4) An applicant who is not a named insured or a relative of a named
insured covered for additional personal injury protection benefits, and who
is an occupant of an insured motor vehicle covered for additional personal
injury protection benefits or a motor vehicle operated by a person covered
for additional personal injury protection benefits, and who sustains a
personal injury through the use or operation of the insured motor vehicle
outside of New York State, shall institute the claim against the insurer of
the owner or operator of the insured motor vehicle. Where there is more
than one insurer which would be the source of benefits, the first such
insurer applied to shall process the claim unless the insurers agree among
themselves that another such insurer will accept and pay the claim initially.
(See subdivision (b) of this section.)
(5) An applicant who has exhausted the additional personal injury
protection benefits available under the initial sources as set forth in this
section, shall then apply for benefits from the next available source
providing a higher level of additional personal injury protection benefits.
This latter source shall provide benefits to the extent that the total limit
available under such latter source exceeds the amount available under the
initial sources as set forth in this section. This process will repeat until all
available additional personal injury protection benefit sources have been
exhausted.
(b) Any insurer paying additional personal injury protection benefits as provided
in this section shall be reimbursed by the other insurers for their proportionate share
14
of the costs of the claim and the allocated expenses of processing the claim, in
accordance with the other coverage; nonduplication paragraph of the additional
personal injury protection endorsement contained in section 65-1.3 of this Part.
65-3.14 Scope of coverage. (a) An insurer shall be liable only for the payment
of benefits for losses caused by the accident, including those caused by the
aggravation of preexisting conditions.
(b) An insurer shall pay benefits to an applicant for losses arising out of an
accident in the following situations:
(1) where coverage has been excluded for an applicant operating a
vehicle while in an intoxicated condition or while the applicant’s ability is
impaired by the use of a drug, if such intoxicated or drugged condition was
not a contributing cause of the accident causing the injuries;
(2) where coverage has been excluded for an applicant operating or
occupying a motor vehicle known to the applicant to be stolen, and the
applicant is an involuntary operator or occupant of said vehicle;
(3) where there is no physical contact between the applicant and a
motor vehicle or motorcycle which is the proximate cause of the injury;
(4) where the motor vehicle or motorcycle is used without the specific
permission of the owner, but is not a stolen vehicle; or
(5) where the accident arises out of repairing, servicing or otherwise
maintaining a motor vehicle or a motorcycle, other than in the course of a
business, and for which no charge or fee is contemplated.
65-3.15 Computation of basic economic loss. When claims aggregate to
more than $50,000, payments for basic economic loss shall be made to the
applicant and/or an assignee in the order in which each service was rendered or
each expense was incurred, provided claims therefor were made to the insurer prior
to the exhaustion of the $50,000. If the insurer pays the $50,000 before receiving
claims for services rendered prior in time to those which were paid, the insurer will
not be liable to pay such late claims. If the insurer receives claims of a number of
providers of services, at the same time, the payments shall be made in the order of
rendition of services.
65-3.16 Measurement of no-fault benefits. (a) Medical expenses.
(1) Payment for medical expenses shall be in accordance with fee
schedules promulgated under section 5108 of the Insurance Law and
contained in Part 68 of this Title (Regulation 83).
(2) Where an applicant receives treatment from a health maintenance
organization, an Insurance Law article 43 corporation, a Veterans
Administration hospital or provider, or any other provider which does not
render specific charges for services, or where any such charges are
15
indeterminate, the applicant shall be entitled to payment of benefits equal to
the value for equivalent services rendered by a provider as limited by section
5108 of the Insurance Law and Part 68 of this Title (Regulation 83).
(3) Pursuant to section 5102(a)(1) of the Insurance Law, an insurer
shall not be liable for the payment of medical and other benefits
enumerated in section 5102(a)(1) if, during a period of one year from the
date of the accident, no such expenses have been incurred by the
applicant.
(4) The term “nursing”, as used in section 5102(a)(1)(i) of the
Insurance Law, shall include but not be limited to all necessary services
rendered to the eligible injured person by a licensed practical nurse.
(5) If the applicant’s injuries warrant occupational therapy or
rehabilitation based on an attending physician’s recommendation, or if the
injuries have rendered the applicant unable to resume the applicant’s
occupation, the insurer shall inform the applicant of the coverage for
occupational therapy or rehabilitation required by section 5102(a)(1)(ii) of
the Insurance Law, and the insurer shall assist the applicant in obtaining
such occupational therapy and rehabilitation.
(6) The term “any other professional health services”, as used in
section 5102(a)(1)(iv) of the Insurance Law, this Part and approved
endorsements, shall be limited to those services that are required or would
be required to be licensed by the State of New York if performed within the
State of New York. Such professional health services should be necessary
for the treatment of the injuries sustained and within the lawful scope of the
licensee’s practice. Charges for the services shall be covered pursuant to
schedules promulgated under section 5108 of the Insurance Law and Part
68 of this Title (Regulation 83). The services need not be initiated through
referral by a treating or practicing physician.
(7) The scope of the term “religious methods of healing recognized by
the laws of this State”, as used in section 5102(a)(1)(iii) of the Insurance
Law, this Part and approved endorsements, is a method recognized under
article 131 of the Education Law. Charges for such services shall be
covered pursuant to schedules promulgated under section 5108 of the
Insurance Law.
(8) Services rendered to the eligible injured person by a certified or
licensed home health care agency shall be considered a medical expense
payable under section 5102(a)(1) of the Insurance Law.
(9) Pursuant to section 5102(b)(2) of the Insurance Law, when the
applicant is entitled to workers’ compensation benefits due to the same
accident, the workers’ compensation carrier shall be the sole source of
reimbursement for medical expenses.
16
(10) If a provider of health service requires proof of the applicant’s
ability to pay for the services to be rendered as a result of the accident, the
insurer shall provide the applicant or the provider (if the applicant is entitled
to benefits) with a letter stating that the applicant has coverage under its
policy and that the necessary medical expenses incurred as a result of the
accident are covered expenses subject to the policy limits and conditions
and applicable fee schedules.
(11) Within 30 calendar days of a submission by a dentist or plastic
surgeon of a proposal for a course of treatment and charges, an insurer
shall review such proposal and notify the provider as to whether or not
payment will be made in accordance with the proposal. The foregoing shall
apply to nonemergency situations and when the course of treatment is
expected to involve covered expenses of $250 or more.
(12) A provider of health care services is not eligible for reimbursement
under section 5102(a)(1) of the Insurance Law if the provider fails to meet
any applicable New York State or local licensing requirement necessary to
perform such service in New York or meet any applicable licensing
requirement necessary to perform such service in any other state in which
such service is performed.
(b) Loss of earnings. In determining loss of earnings from work:
(1) Benefits from other sources shall not be considered as an offset
against or a deduction from loss of earnings, unless article 51 of the
Insurance Law expressly provides for such offset or deduction.
(i) Within the meaning of section 5102(a)(2) of the Insurance
Law, insurers shall not take a deduction for statutory or contractual
wage continuation plans which are diminished or exhausted as
payments are made or when accumulated sick leave time is used. In
order for an insurer to be entitled to offset or deduct payments received
by a claimant under a particular wage continuation plan, the plan must
meet all of the following conditions:
(a) the applicant must be entitled to receive the same level of
wage continuation benefits for a subsequent unrelated accident or
illness when he or she returns to work after recovering from the
injuries sustained in the motor vehicle accident;
(b) benefits for a subsequent unrelated accident or illness
must be equal in both time and amount to the wage continuation
benefits to which the applicant was entitled as a result of the
injuries suffered in the motor vehicle accident; and
(c) wage continuation benefits for a subsequent disability
must be immediately available, without any requirement that the
17
applicant work a stated period of time before full benefits are
restored.
(ii) Within the meaning of section 5102(a)(2) of the Insurance
Law, insurers shall take a deduction for any payments made by an
employer on a voluntary basis.
(iii) Within the meaning of section 5102(a)(2) of the Insurance
Law, insurers shall not take a deduction for contractual or voluntary
long-term disability plans, which generally become effective six months
after the date disability begins.
(2) Insureds covered by wage continuation plans which meet the
criteria for deduction set forth in subparagraph (1)(i) of this subdivision, are
entitled to a premium reduction to reflect the insurer’s reduced exposure to
loss, pursuant to section 2330 of the Insurance Law. Insurers shall grant
the premium reduction upon receipt of information that indicates the
insured is covered by such wage continuation plan.
(3) Loss of earnings from work shall not necessarily be limited to the
applicant’s actual level of earnings at the time of the accident, but may also
include demonstrated future earnings reasonably projected.
(4) An applicant, whose unemployment was the result of the seasonal
nature of the work which the applicant usually performed, shall be entitled
to receive payments for loss of earnings from work during the claimed
period of disability arising from the accident which coincides with the
seasonal period of employment.
(5) Where the injury renders an unemployed applicant ineligible to
receive unemployment benefits, the applicant shall be entitled to receive
payments for loss of earnings from work equivalent in value to the
unemployment benefits which the applicant would otherwise have received.
If an unemployed applicant is eligible for disability benefits pursuant to
Workers’ Compensation Law, section 207 (sick unemployed fund), the no-
fault insurer shall supplement such benefits to bring them up to the level of
the lost unemployment benefits. If the unemployed applicant is not eligible
for such disability benefits, the insurer shall pay an amount equal to the lost
unemployment benefits. Such loss of earnings is eligible basic economic
loss, but is not subject to the 20-percent offset from loss of earnings
provided for in section 5102(b)(1) of the Insurance Law.
(6) If the applicant, while disabled, is discharged from employment
solely because of inability to work due to the injury, benefits for basic
economic loss shall continue at the same level while the disability
continues.
(7) If an applicant, while disabled, is discharged from employment,
benefits shall cease if the position would have been lost had the accident
not occurred (e.g., plant shutdown, strike, etc.). However, the insurer shall
18
reimburse the applicant for benefits lost which would have been received
had the applicant not been disabled (e.g., union strike benefits,
unemployment, etc.).
(8) During the continuance of a disability arising from a covered
accident, loss of earnings benefits due and payable must be paid
periodically, at least once in every 30 calendar days.
(9) Refusal by an eligible injured person to accept reasonable
rehabilitative treatment may be the basis for denial of future payment of
benefits for loss of earnings from work and may be used as evidence to
dispute the reasonableness or necessity of any further expense or loss.
(10) Substitute services. (i) Where an applicant sustains expenses in
obtaining services in lieu of those such person would have performed for
income, but still suffers a net loss of earnings from work which the applicant
would have performed, such loss of earnings is eligible basic economic loss
and shall be subject to the offsets provided for in section 5102(b) of the
Insurance Law; and the cost of substitute services reasonably sustained is
also eligible basic economic loss, but shall not be subject to such offsets.
(ii) Where an applicant has a claim for both substitute services
and loss of earnings from work, the claim for substitute services shall
be primary in computing the loss of earnings benefit payable.
(11) Monthly work loss limit. The monthly limitation on the aggregate of
work loss and substitute services shall not be prorated in the event that one is
unable to work or is required to obtain substitute services for a period less
than one month. A month shall be each consecutive period of 30 days
beginning with the date of the accident unless the injury extends for more than
one year, in which case there shall be 12 monthly payment periods for the
period from the date of accident to each annual anniversary of the accident
date.
(12) The maximum first-party benefit payable for loss of earnings from work
under the mandatory coverage is $1,000 per month for claims arising from
accidents occurring prior to November 12, 1991 and $2,000 per month for
claims arising from accidents occurring on and after November 12, 1991.
(13) Lump-sum settlement for loss of earnings. (i) An Insurer may at its
option enter into a lump-sum settlement agreement for the payment of first-
party benefits, provided that competent medical testimony establishes that:
(a) the period of disability will extend for at least three
years beyond the date of the accident; and
(b) the settlement would be of material benefit to the
applicant, occupationally and from a rehabilitative standpoint.
19
(ii) Lump-sum settlements shall be permitted only for the
payment of loss of earnings from work and may be reduced to the
present value of net benefit payments computed on the basis of a six
percent annual interest factor and any other applicable offsets.
(iii) No lump-sum settlement shall be permitted unless the
form for lump-sum settlement agreement, Appendix 13-A, infra, is
executed by the parties specified thereon and approved by an arbitrator
or a court of competent jurisdiction in accordance with the provisions of
this subpart.
(c) Other reasonable and necessary expenses sustained. Where the applicant
sustains other reasonable and necessary expenses, such services must be actually
performed for a charge by a person who is not legally obligated to render them and
would not ordinarily perform such services as part of a family relationship; provided,
however, that if a member of a family or relative suffers pecuniary loss in order to
render such services, such person shall be reimbursed to the extent of the
reasonable value of such services.
65-3.17 Explanation of Benefits. At least for every six month period during
which any benefits are paid, the insurer shall forward an Explanation of Benefits
(EOB) to the eligible injured person and such person’s attorney. The first six month
period shall commence on the date of the accident and the EOB shall be mailed
within 60 days of the conclusion of the period selected by the insurer. Such EOB
shall include, at a minimum, the name of the payee, a description of the service or
benefit claimed and the amount paid. It shall also include the Fraud Warning
Statement prescribed on the Application for Motor Vehicle No-Fault Benefits (NYS
Form N-F2) contained in Appendix 13 and the name, address and telephone number
of the insurer representative to whom questions should be directed.
65-3.18 Releases. Except as provided in paragraph 65-3.17(b)(13) of this
Subpart (lump-sum settlements), there shall be no settlement nor any release,
express or implied, for mandatory or optional personal injury protection benefits
(Mandatory PIP or Additional PIP benefits).
65-3.19 Offsets. (a) State or Federal Workers’ Compensation Law benefits that
are to be deducted from first-party benefits or additional first-party benefits in
accordance with this Part shall not include payments made under any workers’
compensation law of the Dominion of Canada or any of its provinces.
(b) Federal social security disability benefits that are to be deducted from first-
party or additional first-party benefits shall include, but not be limited to, disability
benefits provided for under the Railroad Retirement Act.
(c) (1) If any source of workers’ compensation benefits, or disability benefits
under article 9 of the Workers’ Compensation Law, denies liability for payment of
benefits, in whole or in part, the insurer responsible for the payment of first-party or
additional first-party benefits shall pay benefits without deducting the withheld
workers’ compensation or disability benefits; provided, however, that the applicant
executes a prescribed agreement to pursue workers’ compensation or New York
20
State disability benefits (NYS Form N-F 9), which shall obligate the applicant to
diligently pursue the claim and to repay first-party benefits equal to the withheld
amounts in the event such amounts are eventually paid to the applicant. The insurer
is entitled to independent verification of the claim in accordance with this subpart. If
the applicant paid an attorney’s fee out of the proceeds of the award, pursuant
thereto, the amount of the attorney’s fee shall be deducted from the repayment.
(2) The insurer should send a copy of the completed agreement to the
local district office of the Workers’ Compensation Board nearest the
applicant’s residence. Thereafter, the Workers’ Compensation Board will
give the insurer notice of the applicant’s hearing, so that the insurer may be
present. Although the insurer may not be a party to such hearing, it may
submit evidence to the referee and may request that the referee put
specific questions to the parties.
(3) If the applicant will not execute the agreement and the automobile
insurer is held ultimately liable, such insurer shall not on that account be
responsible for the payment of an attorney’s fee or interest on the late
payment. To the extent that any reimbursement due the insurer is not
made by the applicant, the insurer may thereafter deduct such amounts
from any future first-party benefits due on the claim.
(d) When it becomes apparent that an applicant, who is receiving no-fault first-
party benefits, will be disabled for more than one year, the insurer shall proceed as
follows:
(1) Forward to the applicant, in triplicate, the prescribed agreement to
pursue social security disability benefits (NYS Form N-F-8) and a self-
addressed, stamped return envelope. The applicant shall bring this form to
the Social Security Administration (SSA) and, when completed, one copy
will be retained by the SSA, one will be retained by the applicant and one
will be returned by the applicant to the insurer in the self-addressed, return
envelope.
(2) Pursuant to the agreement, the insurer shall continue to pay first-
party benefits until the applicant begins receiving social security disability
benefits.
(3) The insurer, when notified by the Social Security Administration of
the amount of the award and the effective date thereof, shall, as of the
effective date, reduce the applicant’s first-party benefits in an amount equal
to the monthly social security disability benefits awarded on account of the
applicant’s injury, inclusive of awards made to the applicant’s spouse and
dependents on account of the injury. However, if the applicant paid an
attorney’s fee out of the proceeds of the award, pursuant thereto, the
insurer shall not take credit for that portion of the award in computing the
amount of the reduction.
(4) In the event that the applicant fails to execute the agreement, the
insurer may, beginning the 27
th
week after the accident, or 35 calendar
21
days after the agreement was forwarded to the applicant (the extra five
calendar days allowed are for mailing) in the event the 27
th
week has
passed, estimate the social security disability benefit it believes the
applicant is entitled to on account of the automobile accident and begin
reducing the applicant’s first-party benefits accordingly. If it is later
determined that no such social security disability benefits were due the
applicant or that the estimate made by the automobile insurer was too high,
the insurer shall pay the applicant for benefits due but shall not on that
account be responsible for an attorney’s fee or interest on the late
payment.
(5) To the extent that any reimbursement due the insurer pursuant to
the agreement is not made by the applicant, the insurer may thereafter
deduct such amounts from any future no-fault benefits due on the claim.
(e) Workers’ compensation or disability benefits liens reimbursement of
section 5102(b)(2) offset. (1) Whenever a lien is asserted against the
proceeds of any tort recovery made pursuant to section 5104(a) of the
Insurance Law for workers’ compensation benefits paid pursuant to any
other State or Federal law, the no-fault insurer shall make the claimant
whole in a manner consistent with the following examples:
(i) Pursuant to section 5102(b)(2), the no-fault insurer takes
an offset of $15,000 from first-party benefits due claimant. Claimant
recovers $25,000 in an action brought pursuant to section 5104(a).
Workers’ compensation lien of $15,000, less the workers’
compensation provider’s share of expenses and attorney’s fees, in
the amount of $5,000 is satisfied out of the $25,000 recovery. In
order to make the claimant whole, the no-fault insurer shall pay the
claimant $10,000 in first-party benefits. The amount owed to the
claimant is the net amount of the satisfied lien.
(ii) Pursuant to section 5102(b)(2), the no-fault insurer takes
an offset of $15,000 from first-party benefits due claimant. Claimant
recovers $10,000 in an action brought pursuant to section 5104(a),
which is the total amount available to satisfy the judgment or
settlement. Workers’ compensation lien of $15,000 is compromised
to $5,000, less the provider’s share of expenses and attorney’s fees,
in the amount of $2,000 and is satisfied out of the $10,000 recovery.
In order to make the claimant whole, the no-fault insurer shall pay
the claimant $3,000 in first-party benefits. The amount owed to the
claimant by the no-fault insurer is the net amount of the
compromised lien, not the full amount of the no-fault insurer’s offset.
(iii) Pursuant to section 5102(b)(2), the no-fault insurer takes
an offset of $40,000 from first-party benefits due claimant. The
workers’ compensation provider pays an additional $20,000 in
benefits pursuant to the state’s Workers’ Compensation Law.
Claimant recovers $200,000 in an action brought pursuant to section
5104(a). The workers’ compensation lien of $60,000 less the
22
provider’s share of expenses and attorney’s fees is satisfied out of
the $200,000 recovery. In order to make the claimant whole, the
automobile insurer shall pay the claimant $40,000 in first-party
benefits. The amount owed the claimant by the no-fault insurer can
never exceed the amount of the section 5102(b)(2) offset taken by
the no-fault insurer.
(2) In lieu of the procedure set forth in paragraph (1) of this
subdivision, subject to acceptance by the workers’ compensation or
disability benefits provider, the claimant may assign the payment right to
the workers’ compensation or disability benefits provider having the lien, as
an alternative to the workers’ compensation or disability benefits provider
obtaining satisfaction of its lien directly from claimant’s recovery. The
assignment shall be effective only if there has been a recovery made
pursuant to section 5104(a) of the Insurance law. The maximum obligation
of the no-fault insurer shall be limited to the amount of the lien which would
have been satisfied out of the recovery, but for the assignment and shall, in
no event, exceed the amount of the offset taken by the no-fault insurer
under section 5102(b)(2) of the Insurance Law. The no fault insurer shall
honor such assignment by paying first-party benefits directly to the workers’
compensation or disability benefits provider for appropriate credit toward
satisfaction of its lien.
(3) Under paragraph (2) of this subdivision, the no-fault insurer shall
either pay or deny in whole or in part on the prescribed denial of claim form
(NYS Form N-F-10) within 30 days after submission of proof that the
workers’ compensation or disability benefits lien has been satisfied or that
the provider, as assignee, has effected such recovery.
(4) Under paragraph (3) of this subdivision, the no-fault insurer shall,
provided proof of assignment has been received, either pay the workers’
compensation or disability benefits provider or deny payment in whole or in
part on the prescribed denial of claim form (NYS Form N-F-10) within 30
days after receipt of proof of recovery by the claimant in an action brought
pursuant to section 5104(a) of the Insurance Law.
(5) Failure to make timely payment, as provided for in paragraph (3) or
(4) of this subdivision, shall subject the no-fault insurer to the interest,
attorney’s fees and arbitration provisions of sections 65-3.10 and 65-3.11
of this Subpart and Subpart 65-4.
(f)(1) Whenever an eligible injured person is entitled to disability
benefits under article 9 of the Workers’ Compensation Law, the insurer
shall be entitled to an offset equal to the lesser of (a) 50 percent of the
applicant’s average weekly wage loss not to exceed $170 per week, or (b)
the actual dollar amount of the disability benefits being received where the
employer’s plan provides a maximum payment of less than $170 per week.
The $170 per week previously referred to shall be adjusted whenever
section 204 of the Workers’ Compensation Law is amended to provide a
higher statutory dollar maximum. The offset shall be applicable during the
23
statutory 26-week benefit period beginning seven days after the accident
date except in the case where lower benefits are paid in exchange for a
longer benefit period. In no event shall the offset for New York State
disability benefits exceed the weekly statutory dollar maximum multiplied by
the maximum statutory benefit period (currently $170 x 26 weeks =
$4,420).
(2) The insurer shall provide the applicant with a notice and proof of
claim for disability benefits (DB 450), which has been printed on buff-
colored paper and, in addition, shall notify the applicant’s employer that
such employer is required to process the applicant’s disability benefits
claim if its employees are covered for such benefits by the Workers’
Compensation Law. The notification to the employer should be sent along
with the Employer’s Wage Verification Report (NYS Form N-F-6). Unless
the insurer has complied with the above, it shall not take an offset for New
York State disability benefits until it verifies that the applicant is actually
receiving statutory disability benefits.
(3) For all qualified wage continuation plans, (referred to in
subparagraph 65-3.17(b)(1)(i) of this subpart) which provide benefits equal
to less than 100 percent of the employee’s salary, the insurer should
reduce the amount paid under the plan by the amount required to be paid
in satisfaction of the New York State Disability Law. Only the excess over
the New York State Disability Benefits is a qualified wage continuation plan
benefit.
Example: A B
Gross Monthly Earnings $6,000 $4,000
Monthly Qualified Wage
Continuation
Plan Benefit $3,000
NYS Disability offset -680
Insurer’s Qualified Wage
Continuation Plan Offset -$2,320
-$2,320
Gross Lost Earnings $3,680 $1,680
First-party Benefit For Loss of
Earnings Limited to Maximum of $2,500 $2,500 $1,680
Less NYS Disability Offset
1
680 680
$1,820 $1,000
Less 20% Offset $ 364
$ 200
Net Loss of Earnings Benefit $1,456
$ 800
1
If NYS disability benefits are taxable, the offset should be deducted from the lesser of gross
lost earnings or $2,500, prior to the 20% offset.
24
(4) The insurer, when making its first payment for loss of earnings,
shall include a written explanation of the computation of the New York
State disability offset taken.
65-3.20 Reimbursement and trust agreement. An insurer may request that
an applicant assign to the insurer such applicant’s right to commence an action,
pursuant to section 5104(b) of the Insurance Law, before two years after the accrual
thereof; provided, however, that such request must be accompanied by a clear,
detailed explanation that the applicant has the right to refuse such request and that
such refusal will not prejudice the applicant’s eligibility for the payment of any first-
party benefits to which the applicant is entitled. If, as a result of such assignment,
the insurer recovers an amount in excess of the amount paid or payable to the
applicant in first-party benefits, such excess amount shall be remitted to the
applicant less a pro rata share of collection costs.
11 NYCRR 65-4
(Regulation 68-D)
Arbitration
65-4.1 Applicability of arbitration procedures under Article 51 of the
Insurance Law. This subpart shall apply to insurers, and the term insurer, as used
in this subpart, shall include both insurers and self-insurers, as those terms are
defined in this Part and article 51 of the Insurance Law, and shall also include the
Motor Vehicle Accident Indemnification Corporation (MVAIC) created pursuant to
article 52 of the Insurance Law and any company or corporation providing insurance
pursuant to section 5103(g) of the Insurance Law.
65-4.2 Initiation of optional arbitration procedures under section 5106(b)
of the Insurance Law for arbitrations filed with an organization designated by
the Superintendent on and after December 1, 1999.
(a) Administration by an organization designated by the Superintendent. (1)
Section 5106 of the Insurance Law requires that the Superintendent of
Insurance promulgate simplified procedures for the resolution by arbitration of
no-fault disputes.
(2) Chapter 892 of the Laws of 1977 provides for the establishment of
revised optional arbitration systems for the resolution of no-fault disputes.
These changed procedures for the administration of the arbitration system
provide for initial review of all arbitration requests by an organization designated
by the Superintendent. The designated organization, acting on behalf of the
superintendent, is authorized to receive, attempt to conciliate and forward to
arbitration all requests for arbitration that it cannot conciliate.
(3) All optional arbitrations pursuant to section 5106(b) of the Insurance Law
will be administered by an organization designated by the Superintendent.
(4) No-Fault Optional Arbitration Advisory Committee. The superintendent
shall select an advisory committee composed of 12 members to review the
operations and the actual costs of the optional arbitration procedures set forth in
this subpart. Not more than four of the members of the advisory committee shall
be representatives of self-insurers.
(5) Oversight. The superintendent shall oversee the operation procedures of
the designated organization with respect to the administration of the optional
arbitration process. Such oversight shall include, but not be limited to, access
to all systems, databases, and records related to the optional arbitration
process. In addition, the designated organization shall make reports to the
superintendent in whatever form the superintendent shall prescribe.
2
(b) Procedures. (1) Initiation of arbitration.
(i) An applicant for benefits may initiate arbitration proceedings by mailing
a copy of the denial of claim form prescribed by subdivision 65-3.4(c) of this
Part, upon which the applicant has entered the reason(s) for contesting the
denial, together with a detailed listing and calculation of all incurred expenses
in dispute, indicating the dates upon which the claims for incurred expenses
were submitted to the insurer, to the address designated on the denial of
claim form.
(ii) If there is a dispute with respect to any matter which is arbitrable
pursuant to section 5106 of the Insurance Law and a denial of claim form has
not been issued, the applicant may initiate arbitration by completing a
prescribed no-fault arbitration request form (Form AR) and forwarding the
original and one copy to the designated organization at the address
designated on the form, and one copy to the insurer against which arbitration
is being requested.
(iii) The denial of claim form or the arbitration request form shall be
accompanied by a check or money order for $40 payable to the designated
organization. This filing fee shall be returned to the applicant directly by the
insurer, if the applicant prevails in whole or in part.
(iv) As a condition precedent to arbitration where there is no denial of
claim by an insurer, evidence of attempts to settle the dispute must be
detailed on the arbitration request form.
(v) In the absence of a denial of claim form, a dispute shall be considered
arbitrable if the claim is overdue as described in subdivision (a) of section 65-
3.9 of this Part and a demonstrable attempt was made by the applicant to
obtain payment or an explanation from the insurer of the continued
nonpayment of the claim.
(vi) All items on the no-fault arbitration request form (Form AR) must be
completed in full. An explanation must be provided for any omitted spaces
on the form, which may be obtained, upon request, from the designated
organization by writing to the address designated on the form, which is
included in Appendix 13 of this Title.
(2) Initial review by the conciliation center.
(i) The designated organization shall establish a conciliation center, which
shall review all requests for arbitration and assign file numbers thereto, which
shall be used by the designated organization and the parties thereto to
identify the case.
(ii) Each insurer shall designate, for each claims office used by the
insurer to handle New York no-fault claims, a responsible staff member
3
whom the conciliation center can contact to determine whether the no-fault
dispute for which arbitration has been requested can be resolved without the
need for arbitration. Since the conciliation staff will attempt to resolve the
dispute by telephone, facsimile, e-mail, or other appropriate means, the
insurer's designated representative shall have the authority to bind the
insurer to any agreement reached. The insurer shall notify the conciliation
center of the designated representative in writing and must immediately
notify the conciliation center of any change in such designation.
(iii) If it appears, after review, that the dispute may be resolved without
arbitration, the conciliation center will communicate with the parties and
attempt through conciliation to resolve the dispute.
(a) If all the issues in dispute are resolved through conciliation, by the
insurer agreeing to pay and the applicant agreeing to accept all or a
portion of the amount in dispute, the insurer shall, in addition, return the
filing fee to the applicant. If the claim was overdue, the insurer shall also
pay the applicable interest.
(b) If the arbitration was initiated by use of a no-fault arbitration
request form (Form AR) and it is subsequently established that the claim
and any applicable interest and attorney fees were paid at least 20
calendar days prior to the submission of the completed AR form, the
filing fee shall not be returned to the applicant. In such instance, an
additional $100 service and processing fee shall be payable by the
applicant to the designated organization.
(iv) If it appears to the conciliation center that the dispute cannot be
resolved through conciliation within 45 days, the conciliation center will refer
the request for arbitration as prescribed in this section and the applicant shall
be so advised. The conciliation center may, however, withhold such referral
pending receipt from the applicant of pertinent and available information that
has been requested.
(3) Prior to transmittal to arbitration, the insurer may make a non-binding
written offer to resolve the dispute. Such offer, if not accepted by the applicant,
shall be transmitted to the arbitration forum, but shall not be disclosed to the
arbitrator. The parties to the dispute shall also not disclose the offer to the
arbitrator.
(4) All disputes remaining after expiration of the conciliation period shall be
forwarded for arbitration.
(c) Financing.
(1) The cost of administering the conciliation function, reduced by any fees
collected, shall be paid annually by insurers (including self-insurers and MVAIC)
to the designated organization upon receipt of a statement therefrom. This cost
shall be distributed among insurers in an equitable manner approved by the
Superintendent of Insurance. This distribution shall, to the extent practicable, be
4
a function of the degree to which an insurer is named as a respondent in
conciliation proceedings of the designated organization.
(2) Semiannually, commencing December 1, 1999 and continuing every six
months thereafter, the designated organization shall prepare an estimate of the
expenses expected to be incurred for the operation of the conciliation function
during the subsequent six-month period. The projected cost of the conciliation
function shall be assessed on a proportionate basis to those insurers named as
respondents in the preceding calendar year and shall be subject to the approval
of the superintendent. The designated organization shall send to each
applicable insurer a bill for the amount due and any payment due shall be made
to the designated organization within 30 days after billing date.
(3) On an annual basis, as of December 31st of each year, the designated
organization shall prepare a detailed analysis of the actual costs incurred for the
operation of the conciliation function. This analysis shall be forwarded to the No-
Fault Optional Arbitration Advisory Committee and the superintendent on or
before April 30th of each year. The No-Fault Optional Arbitration Advisory
Committee shall notify the designated organization and the superintendent
whether it accepts or rejects the designated organization's cost analysis in
whole or in part. In the event that the designated organization and the No-Fault
Optional Arbitration Advisory Committee cannot resolve any differences that
may exist, such differences will be referred to the superintendent for resolution.
The superintendent's decision shall be binding on the designated organization
and insurers.
(4) Once the designated organization submits a final cost analysis that has
either been approved by the No-Fault Optional Arbitration Advisory Committee
or resolved by the superintendent in the event of a dispute, the designated
organization shall send to each applicable insurer an accounting of the actual
assessment. Any adjustment shall be made to the bill for the subsequent
estimated assessment, as illustrated by the following example:
EXAMPLE
(1) Total conciliation cases closed during year 30,000
(2) Cases in which Insurer A was named as a respondent in the
conciliation proceeding 1,250
(3) Insurer A's Assessment Percentage = (2)/(1) 4.167%
(4) Actual Expenses of the conciliation function reduced
by amounts received through fees collected $2,500,000
(5) Insurer A's actual expense = (3)*(4) $104,175
(6) Insurer A's Estimated Assessment $102,000
(7) Insurer A's Debit or (Credit) = (5)-(6) $2,175
65-4.3 Jurisdiction of arbitration forums. (a) Insurance Department
Arbitration (IDA) forum. IDA jurisdiction shall be limited to requests for No-Fault
arbitration filed prior to December 1, 1999 and shall include only those disputes
where the remaining issues after the expiration of the conciliation period involve:
5
(1) correct computation of health service provider fees, whether or not such
fees are specifically covered by the fee schedules promulgated in Part 68 of this
Title (Regulation 83);
(2) where the amount in dispute is less than $400 and such dispute does not
involve a coverage question or affect the outcome of any other portion of the
applicant’s claim; or
(3) whether the claim was overdue at the time it was paid, how long the claim
was overdue, or whether the correct amount of interest or attorney’s fee on an
overdue claim was paid.
(b) No-Fault Arbitration forum. All disputes remaining after expiration of the
conciliation period, involving issues other than those to be resolved pursuant to
subdivision (a) of this section, shall be forwarded to the No-Fault Arbitration forum
which shall be the forum for their resolution.
(c) Where a request for arbitration involves issues which fall within the
jurisdiction of both of the forums specified in this paragraph, the dispute shall be
resolved by the No-Fault Arbitration forum, except disputes specified in paragraph
(a)(1) of this section and filed prior to December 1, 1999 shall be resolved by IDA
arbitration.
65-4.4 Insurance Department Arbitration (IDA) forum procedure. (a)
Notice. If the dispute is subject to IDA arbitration, the parties will be notified by the
IDA, in writing, that the dispute will be resolved by arbitration on the basis of written
submissions of the parties. All such submissions shall be received by the IDA within
30 calendar days of the date of mailing of the notice. No oral arguments will be
permitted. In order to facilitate receipt of evidence by IDA, the parties may forward
their submissions prior to receipt of the above notification.
(b) Consolidation. The IDA may consolidate disputes if the claims arose out of
the same accident and involve common issues of fact.
(c) Designation of arbitrators. The arbitrator shall be a senior member of the
Insurance Department staff designated by the superintendent to serve as an IDA
arbitrator and shall not be the same person who attempted to conciliate the dispute.
(d) Qualifications of the arbitrator. Every IDA arbitrator shall be an examiner
who regularly administers article 51 of the Insurance Law or an attorney. If the issue
in dispute includes a request for an additional attorney’s fee pursuant to section 65-
4.6 of this subpart, the IDA arbitrator shall be an attorney. No person shall serve as
an arbitrator in any arbitration in which such person has any financial or personal
interest. An arbitrator shall disclose to the IDA any circumstance which is likely to
create an appearance of bias or which might disqualify such arbitrator. Upon receipt
of such information, the IDA shall immediately disclose it to the parties. If a party
challenges an arbitrator, the specific grounds for the challenge shall be submitted in
6
writing to the superintendent. The superintendent shall determine whether the
arbitrator should be disqualified and shall inform the parties of that determination,
which shall be conclusive. If an arbitrator should resign, be disqualified or be
otherwise unable to perform necessary duties, the superintendent shall designate
another arbitrator to resolve the dispute.
(e) Evidence. The arbitrator shall be the judge of the relevancy and materiality
of the evidence offered and strict conformity to legal rules of evidence shall not be
necessary. The arbitrator may subpoena documents upon the arbitrator’s own
initiative or upon the request of any party when the issues to be resolved require
such documents. Copies of all documents submitted to the arbitrator shall be
simultaneously transmitted to the other parties. The arbitrator may raise any issue
that the arbitrator deems relevant to making an award that is consistent with the
Insurance Law and Department regulations.
(f) Form and scope of award. The award, which shall be in writing and signed
by the arbitrator, shall state the issues in dispute and contain the arbitrator’s
findings, conclusions and decision based on the Insurance Law and Insurance
Department regulations. In the event that the applicant prevails in whole or in part on
the claim, the arbitrator shall also direct the insurer to:
(1) reimburse the applicant for the amount of the filing fee paid, unless the
filing fee had already been returned to the applicant;
(2) if due under section 5106 of the Insurance Law, pay a reasonable
attorney’s fee in accordance with the limitations set forth in section 65-4.6 of this
subpart; and
(3) in an award of interest, the arbitrator shall compute the amount due for
each element of first-party benefits in dispute, commencing 30 days after proof
of claim therefor was received by the insurer and ending with the day of
payment of the award, subject to the provision of subdivision 65-3.10(c) of this
Part (stay of interest).
(g) Time of award. The award shall be issued no later than 30 calendar days
from the final date submissions must be received. Failure to adhere to the
prescribed time limit shall not nullify the award.
(h) Delivery of award to parties. The award shall be transmitted to the parties,
which shall accept as delivery of the award the placing of the award or a true copy
thereof, in the mail, addressed to the parties and their designated representatives at
their last known addresses, or by any other form of service permitted by law. The
IDA shall note on such award or transmittal letter thereof the date of mailing, and
keep a record of same.
(i) Interpretation and application of procedures. The arbitrator shall interpret
and apply these procedures insofar as they relate to the arbitrator’s powers and
duties. All other procedures shall be administered by the Insurance Department.
7
(j) Payment of award. Insurers shall, within 30 calendar days of the date of
mailing of the award, either pay the amounts set forth in the award or, where
grounds exist, appeal to the master arbitrator as provided for in this Part, which
appeal shall stay payment of the award. The award need not be confirmed into
judgment.
(k) Financing, The Insurance Department shall bill the insurer the sum of $100
whenever the applicant prevails in whole or in part on the disputed claim. Such fee
shall be payable within 30 days after the billing date and shall be utilized to defray
the operating expenses of the department.
65-4.5 No-Fault Arbitration forum procedure. (a) Notice. If a dispute has
been transmitted for arbitration by the Insurance Department or the conciliation
center, the parties will be notified by the designated organization, in writing, that the
dispute will be resolved by arbitration. At the arbitrator’s discretion, if the dispute
involves an amount less than $2,000, the parties shall be notified that the dispute
shall be resolved on the basis of written submissions of the parties. All such
submissions shall be received by the designated organization within 30 calendar
days of the date of mailing of the notice. No oral arguments will be permitted, unless
the arbitrator determines that additional evidence or testimony is necessary. In
order to facilitate receipt of evidence by the designated organization, the parties may
forward their submissions prior to receipt of the above notification.
(b) Special Expedited Arbitration.
(1) Special Expedited Arbitration shall be available for disputes involving
the failure to submit notice of claim within 30 calendar days after the accident
and where it has been detemined by the insurer that reasonable justification for
late notice has not been established.
(2) An applicant may request Special Expedited Arbitration for resolution
of the dispute involving late notice within 30 calendar days after mailing of the
denial of claim by the insurer stating that reasonable justification for late notice
has not been established. At the time of such request, the applicant shall make
a complete submission supporting his or her position. No further submissions
shall be accepted unless requested by the arbitrator.
(3) Applications for Special Expedited Arbitration shall be submitted to
the Conciliation Center of the designated organization and shall comply with the
requirements for initiation of arbitration contained in paragraph 65-4.2(b)(1) of
this Subpart.
(4) The applicant’s submission shall be forwarded by the Conciliation
Center to the insurer within 3 business days of receipt. The insurer may provide
the Center with reasonable special mailing or transmittal instructions to facilitate
the processing of these arbitration requests.
8
(5) The insurer shall respond in writing to the applicant’s submission
within 10 business days after the mailing by the Center. No further submissions
shall be accepted unless requested by the arbitrator.
(6) The dispute shall be resolved solely upon the basis of written
submissions unless the arbitrator concludes that the issues in dispute require
an oral hearing.
(7) The arbitrator shall issue a written decision within 10 business days
after receipt of all written submissions from the parties or at the conclusion of an
oral hearing.
(8) For the purpose of Special Expedited Arbitration, the superintendent
may appoint arbitrators, qualified in accordance with the provisions of this
section, to serve on a per diem basis. Such arbitrators shall contract with the
designated organization. The rate of per diem compensation shall be
determined by the designated organization, after consultation with the No-Fault
Arbitrator Screening Committee subject to the approval of the Superintendent.
Such arbitrators shall be independent contractors, and shall not be employees
or agents of the designated organization or the Insurance Department.
(c) Consolidation. The designated organization shall, except where impracticable,
consolidate disputes for which a request for arbitration has been received, if the
claims involved arose out of the same accident and involve common issues of fact.
(d) Qualifications of arbitrators for a hearing held in New York State.
(1) No-Fault Arbitrator Screening Committee. The superintendent shall
appoint an advisory committee composed of six members, who will review the
qualifications of applicants for the position of no-fault arbitrator for hearings to
be held in New York State and review the performance of the appointed
arbitrators. The screening committee shall make recommendations to the
superintendent pertaining to the appointment, termination and renewal of no-
fault arbitrators. The committee shall consist of one representative of the New
York State Bar Association, one representative of the New York State Trial
Lawyer’s Association, two representatives of the insurance industry selected by
the No-Fault Optional Arbitration Advisory Committee, a nonvoting
representative of the designated organization and a nonvoting representative of
the Insurance Department. Tie votes shall be reported as such to the
superintendent.
(2) A no-fault arbitrator shall be an attorney, licensed to practice law in
New York State, with at least 10 years’ experience which the No-Fault Arbitrator
Screening Committee has determined qualifies such attorney to review and
resolve the issues involved in no-fault insurance disputes. Documentation of
such experience shall be submitted to, and reviewed by, the superintendent
prior to the appointment of an arbitrator.
(3) All no-fault arbitrators shall be appointed by, and serve at the pleasure
of, the superintendent. An arbitrator candidate shall disclose to the
9
superintendent any circumstance, which is likely to create an appearance of
bias, or which might disqualify such person as an arbitrator, and the
superintendent shall determine whether the candidate should be disqualified.
The superintendent shall forward the name of all no-fault arbitrators to the
designated organization, and promptly inform the designated organization of all
additions to, and deletions from, the panel.
(4) No person shall, during the period of appointment as an arbitrator,
have any practice or professional connection with any firm or insurer involved in
any degree with automobile insurance or negligence law. The No-Fault
Arbitrator Screening Committee, subject to the approval of the superintendent,
shall establish any additional qualifications for appointment as a no-fault
arbitrator.
(e) Qualifications of arbitrators for a hearing held outside New York State. For
a hearing which will be held outside New York State, the arbitrator shall be a
licensed attorney in the State or Canadian province where the hearing is held.
(f) Designation of arbitrator. The designated organization shall assign an
arbitrator who will hear the case, and shall submit the name of the arbitrator to each
party to the arbitration. The designated organization shall maintain a file containing
the professional background of each of its no-fault arbitrators, and the information
contained therein shall be available to any party to the arbitration upon written or oral
request.
(g) Conflict of interest and disqualification of arbitrator. No person shall serve
as an arbitrator in any arbitration in which such person has any financial or personal
interest or bias. If a party challenges an arbitrator, the specific grounds for the
challenge shall be submitted in writing to the designated organization, which shall
determine within 15 calendar days after receipt of the challenge whether the
arbitrator shall be disqualified. Such determination shall be final and binding. If an
arbitrator should resign, be disqualified or be otherwise unable to perform necessary
duties, the designated organization shall assign another arbitrator to the case.
(h) Oaths. Arbitrators shall take an annual oath of office. Arbitrators shall
require all witnesses to testify under oath or affirm that their statements are true
under the penalties of perjury.
(i) Time and place of arbitration. The arbitration hearing shall be held in the
arbitrator’s office or any other appropriate place selected by the designated
organization and, to the extent practicable, within the general locale of the
applicant’s residence but, in no event, more than 100 miles from such residence.
The arbitrator shall set the date, time and place for such hearing. At least 15
calendar days prior to the hearing, the designated organization shall send a notice of
hearing to each party. Unless otherwise agreed by the parties, the hearing shall be
scheduled to be held within 60 calendar days of the date of the appointment of the
arbitrator. The parties to the arbitration shall not directly contact the arbitrator at any
time prior to or subsequent to the hearing, but may submit to the designated
organization material intended for the arbitrator.
10
(j) Postponements and adjournments. The arbitrator may for good cause
postpone or adjourn the hearing upon request of a party or upon the arbitrator’s own
initiative. Each party may cause one adjournment without the payment of an
adjournment fee, if the adjournment request is received by the designated
organization at least two business days prior to the scheduled arbitration. There
shall be an adjournment fee of $50 payable to the designated organization by the
party requesting any subsequent adjournment. An adjournment fee of one hundred
dollars ($100) shall be payable to the designated organization by the party causing
any adjournment within two (2) business days prior to the scheduled hearing. Such
fees shall be used to defray the cost of administration of the arbitration forum.
(k) Representation at arbitration. Any party shall either represent itself or be
represented by an attorney.
(l) Record of proceedings. A stenographic record of the arbitration
proceedings shall not be required. However, a party requesting such a record shall
inform the other party or parties of such intent, make the necessary arrangements,
and pay the cost thereof directly to the person or agency making such record. Any
other party or parties to the arbitration shall be entitled to a copy of such record upon
agreeing to share the cost of the total stenographic expense. Whether or not a
stenographic record of the proceeding is made, the arbitrator shall, at a minimum,
record the exhibits offered by each party and the names and addresses of all parties
and witnesses.
(m) Interpreters. Any party wishing an interpreter shall make all arrangements
directly with the interpreter and shall assume the costs of such services.
(n) Attendance at hearings. Persons having a direct interest in the arbitration
are entitled to attend hearings. It shall be discretionary with the arbitrator to permit
the attendance of any other persons.
(o) Evidence. (1) The arbitrator shall be the judge of the relevance and
materiality of the evidence offered, and strict conformity to legal rules of
evidence shall not be necessary. The arbitrator may question any witness or
party and independently raise any issue that the arbitrator deems relevant to
making an award that is consistent with the Insurance Law and Department
regulations.
(2) The arbitrator or an attorney of record in the arbitration may subpoena
witnesses or documents upon the arbitrator’s own initiative or upon the request
of any party, when the issues to be resolved require such witnesses or
documents.
(3) Copies of all documents to be submitted to the arbitrator shall be
simultaneously transmitted to the other parties at least seven calendar days
prior to the hearing. The arbitrator shall determine if all parties received such
documents prior to the commencement of the hearing.
11
(4) If a party to the arbitration intends to introduce an expert witness at the
hearing, the identity of the expert witness must be given to all parties at least
seven calendar days prior to the hearing.
(p) Arbitration in the absence of a party. The arbitration may proceed in the
absence of any party who, after due notice, fails to be present or fails to obtain a
postponement or adjournment. An award shall not be made in favor of an appearing
party solely on the default of another party. The arbitrator shall require the appearing
party to submit such evidence as may be required for the making of an award. The
arbitrator may require the appearance of a party at the hearing if the arbitrator
determines that the party’s appearance is necessary to realize a fair and just
resolution of the dispute and to afford all parties due process.
(q) Reopening of hearing. The hearing may be reopened by the arbitrator, for
good cause, at any time before the award is made.
(r) Time of award. The award shall be made and delivered no later than 30
calendar days from the date the hearing is completed or 30 days from the date of
the designated organization’s transmittal of the final documentary proofs to the
arbitrator. Failure to adhere to this time limit shall not nullify the award.
(s) Form and scope of award. The award shall be in writing in a format approved
by the superintendent. It shall state the issues in dispute and contain the arbitrator’s
findings and conclusions based on the Insurance Law and Insurance Department
regulations. It shall be signed by the arbitrator and shall be transmitted to the parties
by the designated organization with a copy to the Insurance Department. The award
shall contain a decision on all issues submitted to the arbitrator by the parties. In the
event that the applicant prevails in whole or in part on the claim, the arbitrator shall
also direct the insurer to:
(1) reimburse the applicant for the amount of the filing fee paid, unless the
filing fee had already been returned to the applicant;
(2) if due under section 5106 of the Insurance Law, pay a reasonable
attorney’s fee in accordance with the limitations set forth in section 65-4.7 of this
subpart; and
(3) in an award of interest, compute the amount due for each element of
first-party benefits in dispute, commencing 30 days after proof of claim therefor
was received by the insurer and ending with the date of payment of the award,
subject to the provisions of subdivision 65-3.9(c) of this Part (stay of interest).
(t) Award upon settlement.
(1) If the parties settle their dispute during the course of arbitration, the
arbitrator shall set forth the terms of the agreed settlement in an award, which
shall provide that the parties agree that the settlement is final and binding and
shall not be subject to review by a master arbitrator or by a court. If an
attorney’s fee is due under section 5106 of the Insurance Law, such fee shall be
awarded in accordance with the limitations set forth in section 65-4.6 of this
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subpart. The award shall be signed by the arbitrator and shall be transmitted to
the parties by the designated organization, with a copy to the Insurance
Department.
(2) The insurer shall provide the designated organization with the terms of
settlement for transmittal to the arbitrator no later than thirty calendar days
following the scheduled date of the hearing.
(u) Delivery of award to parties. The parties shall accept as delivery of the
award the placing of the award or a true copy thereof in the mail, addressed to the
parties or their designated representatives at their last known addresses, or by any
other form of service permitted by law. The designated organization shall note on
such award or transmittal letter thereof the date of mailing and keep a record of
same.
(v) Interpretation and application of procedures. The arbitrator shall interpret
and apply these procedures insofar as they relate to the arbitrator’s powers and
duties. All other procedures shall be interpreted by the designated organization,
subject to consultation with and approval by the superintendent.
(w) Alternative legal remedies. The designated organization shall not be made a
party to a court proceeding relating to an arbitration award unless the designated
organization’s presence as a party is pertinent to the issues raised in the litigation.
The participation of a party in an arbitration proceeding shall be a waiver of any
claim against an arbitrator or the designated organization for any act or omission in
connection with any arbitration conducted under these rules. The designated
organization shall transmit to the superintendent copies of any legal papers served
upon designated organization or an arbitrator, relating to any stay or appeal of an
arbitration.
(x) Payment of award. Insurers shall, within 30 calendar days of the date of
mailing of the award, either pay the amounts set forth in the award or, where
grounds exist, appeal to the master arbitrator as provided for in this Part, which
appeal shall stay payment of the award. The award need not be confirmed into
judgment.
(y) Arbitrator’s compensation and expenses. At the direction of the
Superintendent, arbitrators shall contract on an annual basis with the designated
organization. The rate of annual compensation shall be determined by the
designated organization, after consultation with the No-Fault Arbitrator Screening
Committee subject to the approval of the Superintendent. Arbitrators shall be
independent contractors, and shall not be employees or agents of the designated
organization or the Insurance Department.
(z) Financing. (1) The cost of administering the No-Fault Arbitration forum shall be
paid annually by insurers (including self-insurers and MVAIC) to the designated
organization upon receipt of a statement therefrom. This cost shall be distributed
among insurers in an equitable manner approved by the Superintendent of
Insurance. This distribution shall, to the extent practicable, be a function of the
13
degree to which an insurer is named as a respondent in No-Fault Arbitration forum
proceedings.
(2) Semiannually, the designated organization shall prepare a budget of the
estimated fees to be incurred for the operation of the No-Fault Arbitration forum
during the subsequent six-month period. The estimated fees of the No-Fault
Arbitration forum shall be assessed on a proportionate basis to those insurers
named as respondents on cases forwarded to No-Fault arbitration in the preceding
calendar year and shall be subject to the approval of the superintendent. The
designated organization shall send to each applicable insurer a bill for the amount
due and any payment due shall be made to the designated organization within 30
days after billing date.
(3) On an annual basis, as of December 31st of each year, the designated
organization shall prepare a detailed analysis of the fees for the operation of the
No-Fault Arbitration forum. This analysis shall be forwarded to the No-Fault
Optional Arbitration Advisory Committee and the superintendent on or before April
30th of each year. The No-Fault Optional Arbitration Advisory Committee shall
notify the designated organization and the superintendent whether it accepts or
rejects the designated organization’s fee analysis in whole or in part. In the event
that the designated organization and the No-Fault Optional Arbitration Advisory
Committee cannot resolve any differences that may exist, such differences will be
referred to the superintendent for resolution. The superintendent's decision shall
be binding on the designated organization and insurers.
(4) Once the designated organization submits a final fee analysis that has
either been approved by the No-Fault Optional Arbitration Advisory Committee or
resolved by the superintendent in the event of a dispute, the designated
organization shall send to each applicable insurer an accounting of the designated
organization’s assessment. Any adjustment shall be made to the bill for the
subsequent estimated assessment, as illustrated by the following example:
EXAMPLE
(1) Total No-Fault Arbitration forum cases closed during year 6,000
(2) Cases in which Insurer A was named as a respondent in the
No-Fault Arbitration forum proceeding
250
(3) Insurer A's Assessment Percentage = (2) /(1) 4.167%
(4) Actual Expenses of the No-Fault Arbitration forum $2,500,000
(5) Insurer A's actual expense = (3)x(4) $104,175
(6) Insurer A's Estimated Assessment $102,000
(7) Insurer A's Debit or (Credit) =(5)-(6) $2,175
65-4.6 Limitations on attorney’s fees pursuant to section 5106 of the
Insurance Law. The following limitations shall apply to the payment by insurers of
applicants’ attorney’s fees for services necessarily performed in the resolution of no-
fault disputes:
14
(a) If an arbitration was initiated or a court action was commenced by an
attorney on behalf of an applicant and the claim or portion thereof was not denied or
overdue at the time the arbitration proceeding was initiated or the action was
commenced, no attorney’s fees shall be granted.
(b) If the claim is resolved by the Insurance Department or the conciliation
center at any time prior to transmittal to an arbitration forum and it was initially
denied by the insurer or overdue, the payment of the applicant’s attorney’s fee by
the insurer shall be limited as follows:
(1) If the resolved claim was initially denied, the attorney’s fee shall be
$80.
(2) If the resolved claim was overdue but not denied, the attorney’s fee
shall not exceed the amount of first-party benefits and any additional first-party
benefits, plus interest thereon, which the insurer agreed to pay and the
applicant agreed to accept in full settlement of the dispute submitted, subject to
a maximum fee of $60.
(3) In disputes solely involving interest, the attorney’s fee shall be equal to
the amount of interest which the insurer agreed to pay and the applicant agreed
to accept in full settlement of the dispute submitted, subject to a maximum fee
of $60.
(c) Except as provided in subdivisions (a) and (b) of this section, the minimum
attorney’s fee payable pursuant to this subpart shall be $60.
(d) For disputes subject to arbitration by the No-Fault Arbitration forum where
one of the issues involves a policy issue as enumerated on the prescribed denial of
claim form (NYS form N-F-10), subject to the provisions of subdivisions (a) and (c) of
this section, the attorney’s fee for the arbitration of all issues shall be limited as
follows:
(1) for preparatory services relating to the arbitration forum or court, the
attorney shall be entitled to receive a fee of up to $70 per hour, subject to a
maximum fee of $1,400; and
(2) in addition, an attorney shall be entitled to receive a fee of up to $80
per hour for each personal appearance before the arbitration forum or court.
(e) For all other disputes subject to arbitration, subject to the provisions of
subdivisions (a) and (c) of this section, the attorney’s fee shall be limited as follows:
20 percent of the amount of first-party benefits, plus interest thereon, awarded by
the arbitrator or court, subject to a maximum fee of $850. If the nature of the dispute
results in an attorney’s fee which could be computed in accordance with the
limitations prescribed in both subdivision (d) and this subdivision, the higher
attorney’s fee shall be payable. However, if the insurer made a written offer
pursuant to paragraph 65-4.2(b)(3) of this Subpart and if such offer equals or
exceeds the amount awarded by the arbitrator, the attorney’s fee shall be based
upon the provisions of subdivision (b) of this section.
15
(f) Notwithstanding the limitations listed in this section, if the arbitrator or a
court determines that the issues in dispute were of such a novel or unique nature as
to require extraordinary skills or services, the arbitrator or court may award an
attorney’s fee in excess of the limitations set forth in this section. An excess fee
award shall detail the specific novel or unique nature of the dispute which justifies
the award. An excess award of an attorney’s fee by an arbitrator shall be appealable
to a master arbitrator.
(g) If a dispute involving an overdue or denied claim is resolved by the parties
after it has been forwarded by the Insurance Department or the conciliation center to
the appropriate arbitration forum or after a court action has been commenced, the
claimant’s attorney shall be entitled to a fee which shall be computed in accordance
with the limitations set forth in this section.
(h) No attorney shall demand, request or receive from the insurer any payment
of fees not permitted by this section.
1
(i) Notwithstanding any other provision of this section and with respect to
billings on and after the effective date of this regulation, if the charges by a health
care provider, who is an applicant for benefits, exceed the limitations contained in
the schedules established pursuant to section 5108 of the Insurance Law, no
attorney’s fee shall be payable by the insurer. This provision shall not be applicable
to charges that involve interpretation of such schedules or inadvertent miscalculation
or error.
65-4.7 Independent health consultant. (a) The designated organization shall
maintain a list of independent health consultants, who will review medical evidence
or examine the eligible injured person upon the request of any arbitrator designated
pursuant to this Subpart.
(b) The independent health consultant shall be selected by the designated
organization from its list and, to the extent practicable, shall be a specialist in the
field requested by the arbitrator. If a medical examination is requested by the
arbitrator, such examination shall be conducted at the health consultant’s office,
which shall be located in the general locale of the applicant’s residence, or at a place
agreed upon by the parties and the consultant.
(c) Within 15 calendar days after the review of medical evidence or
examination of the eligible injured person, the health consultant shall submit to the
designated organization a written report which shall contain the consultant’s advisory
opinion for consideration by the arbitrator. The designated organization shall submit
such report to the arbitrator and the parties.
(d) The independent health consultant’s fee shall include the written report and
be paid by the designated organization, with the cost of such fee charged as an
administrative expense of the No-Fault Arbitration forum.
1
Attorneys should be aware of the Appellate Division Rules prohibiting fees in connection with
the collection of first-party no-fault benefits (22 NYCRR 603.7 (e)(7), 691.20 (e)(7), 806.13(f),
and 1022.3(f)).
16
(e) No person shall serve as an independent health consultant in any
arbitration in which such person has any financial or personal interest or bias. An
independent health consultant shall disclose to the designated organization any
circumstance which is likely to create an appearance of bias or which might serve to
disqualify such expert. Upon receipt of such information, the designated organization
shall immediately disclose it to the parties. If a party challenges a health consultant,
the specific grounds for the challenge shall be submitted in writing. The designated
organization shall determine whether the health consultant should be disqualified
and shall inform the parties of its decision, which shall be final and binding. If a
health consultant should resign, be disqualified or be otherwise unable to perform
necessary duties, the designated organization shall appoint another health
consultant to the case.
65-4.8 Witness fees. (a) No witness fee shall be payable to a person who is a
party to the arbitration.
(b) The arbitrator shall not approve the payment of a fee to a witness
appearing on behalf of an applicant or an assignee, unless the witness was
subpoenaed by the arbitrator or, prior to appearance, the witness’s presence was
determined by the arbitrator to be necessary for resolution of the dispute.
(c) Whenever a witness fee is determined by the arbitrator to be payable, the
cost thereof shall be charged as an administrative expense of the arbitration forum.
(d) Any witness fee awarded pursuant to subdivisions (b) and (c) of this section
shall be determined as follows:
(1) If the witness is testifying as an expert, the fee shall be calculated on
the basis of such witness’s documented usual and customary hourly charge for
an appearance, plus necessary verified disbursements.
(2) Any other witness shall only be entitled to reimbursement for verified
expenses and economic losses necessarily incurred in connection with an
appearance before the arbitrator.
65-4.9 Serving of Notice. The IDA, the designated organization and the
Parties may use facsimile transmission, telex, telegram or other written or electronic
forms of communication to give the notices required by this subpart.
65-4.10 Master arbitration procedures under section 5106(b) of the
Insurance Law.
(a) Grounds for review. An award by an arbitrator rendered pursuant to section
5106(b) of the Insurance Law and section 65-4.4 or section 65-4.5 of this Subpart
may be vacated or modified solely by appeal to a master arbitrator, and only upon
one or more of the following grounds:
(1) any ground for vacating or modifying an award enumerated in article 75
of the Civil Practice Law and Rules (an article 75 proceeding), except the
17
ground enumerated in CPLR subparagraph 7511(b)(1)(iv) (failure to follow
article 75 procedure);
(2) that the award required the insurer to pay amounts in excess of the
policy limitations for any element of first-party benefits; provided that, as a
condition precedent to review by a master arbitrator, the insurer shall pay all
other amounts set forth in the award which will not be the subject of an appeal,
as provided for in section 65-4.4 or section 65-4.5 of this Subpart;
(3) that the award required the insurer to pay amounts in excess of the
policy limitations for any element of additional first-party benefits (when the
parties had agreed to arbitrate the dispute under the additional personal injury
protection endorsement for an accident which occurred prior to January 1,
1982); provided that, as a condition precedent to review by a master arbitrator,
the insurer shall pay all other amounts set forth in the award which will not be
the subject of the appeal, as provided for in section 65-4.4 or section 65-4.5 of
this Subpart;
(4) that an award rendered in an arbitration under section 65-4.4 or section
65-4.5 of this Subpart, was incorrect as a matter of law (procedural or factual
errors committed in the arbitration below are not encompassed within this
ground);
(5) that the attorney’s fee awarded by an arbitrator below was not rendered
in accordance with the limitations prescribed in section 65-4.6 of this Part;
provided that, as a condition precedent to review by a master arbitrator, the
insurer shall pay all other amounts set forth in the award which will not be the
subject of the appeal, as provided for in section 65-4.4 or section 65-4.5 of this
Subpart.
(b) Qualifications of master arbitrators. (1) A master arbitrator shall be an
attorney, licensed to practice law in New York State, who has at least 15 years’
experience which the superintendent has determined qualifies such attorney to
review and resolve the issues involved in no-fault insurance disputes.
Documentation of such experience shall be submitted to, and reviewed by, the
superintendent prior to appointment of a master arbitrator.
(2) All master arbitrators shall be appointed by, and serve at the pleasure
of, the superintendent. A master arbitrator candidate shall disclose to the
superintendent any circumstance which is likely to create an appearance of bias
or which might disqualify such person as a master arbitrator, and the
superintendent shall determine whether the candidate should be disqualified.
The superintendent shall forward the names of all master arbitrators to the
designated organization, and promptly inform it of all additions to, and deletions
from, the panel.
(3) No person shall, during the period of appointment as a master
arbitrator, also serve as an arbitrator under the optional arbitration systems
prescribed in section 5106(b) of the Insurance Law and section 65-4.4 or
18
section 65-4.5 of this Subpart, nor serve as an attorney to a party to any such
arbitration.
(4) All master arbitrators shall take an oath of office.
(5) No person shall serve as a master arbitrator in any master arbitration in
which such person has any financial or personal interest or bias. If a party
challenges a master arbitrator, the specific grounds for the challenge shall be
submitted in writing to the designated organization which, in consultation with
the superintendent, shall determine within 15 calendar days after receipt of the
challenge whether the master arbitrator should be disqualified. Such
determination shall be final and binding. If a master arbitrator should resign, be
disqualified or be otherwise unable to perform necessary duties, the designated
organization shall assign another master arbitrator to the case within seven
calendar days after receipt of notice thereof.
(c) Scope of master arbitration review. (1) Review by a master arbitrator shall
be based solely on submitted documents, including any record made of the
arbitration below, unless a master arbitrator requires oral argument on specified
issues.
(2) Legal briefs shall not be submitted, unless requested by the master
arbitrator.
(3) The master arbitrator shall initially consider and determine whether the
facts alleged in the submitted documents set forth a ground for review pursuant
to subdivision (a) of this section.
(4) If the master arbitrator determines that subdivision (a) of this section
has not been complied with, the master arbitrator shall, in lieu of rendering an
award, deny the request for review. The procedural requirements contained in
this section applicable to a master award, shall also be applicable to a denial of
request for review, but such denial shall not form the basis of an action de novo
within the meaning of section 5106(b) of the Insurance Law.
(5) If the master arbitrator determines that subdivision (a) of this section
has been complied with, the master arbitrator shall proceed to review the matter
and render an award accordingly.
(6) The master arbitrator shall only consider those matters which were the
subject of the arbitration below or which were included in the arbitration award
appealed from.
(d) Procedure for review. (1) If grounds exist, pursuant to subdivision (a) of this
section, any party to an arbitration may request that the arbitration award be vacated
or modified by a master arbitrator.
(2) The request for review by a master arbitrator shall be in writing and
shall be mailed or delivered to the designated organization’s Master Arbitration
administrative office within 21 calendar days of the mailing of the award. The
19
request shall include a copy of the award in issue and shall state the nature of
the dispute and the grounds for review. A request by an applicant for benefits
shall be accompanied by a filing fee of $75, payable by check or money order to
the designated organization. A request by an insurer shall be accompanied by
a filing fee of $325, payable by check or money order to the designated
organization. The failure of a party to enclose the appropriate filing fee with a
timely request for review shall result in a denial of the request for review by a
master arbitrator if such payment is not made within 28 calendar days of the
mailing of the award.
(3) The applicant for master arbitration review shall send, by certified mail,
a copy of its filing papers to the opposing party at the same time that it submits
the request for review to the designated organization.
(4) Within seven calendar days of receipt of the request, the designated
organization shall assign a master arbitrator, selected in sequence from a panel
of master arbitrators appointed by the superintendent, and shall forward to the
master arbitrator a copy of the request for review.
(5) The master arbitrator shall render an award no later than 90 calendar
days after assignment.
(i) Submission of materials. Within 15 calendar days after
assignment, the master arbitrator shall set a date (which date shall not be
more than 45 calendar days after assignment) by which all evidence,
documents and briefs, if any, must be submitted to the master arbitrator by
the parties. The master arbitrator shall give the parties 30 calendar days’
written notice of this date.
(ii) Oral argument. If after receipt of these materials, the master
arbitrator determines that oral argument on specific issues is necessary,
the master arbitrator shall give the parties 10 calendar days’ notice of the
place, time and date for oral argument and the issues to be argued. Oral
argument shall be conducted at the office of the master arbitrator, the
office of the designated organization or at a location agreeable to the
parties and the master arbitrator.
(iii) The master arbitrator may postpone or adjourn the date for
submission of materials or of oral argument to a date within the 90-day
period for good cause shown. A postponement or adjournment shall also
be granted when all the parties agree thereto. The postponement or
adjournment shall not extend the 90-day period for rendering of an award.
(6) The failure of a master arbitrator to adhere to the procedural time
frames, contained in paragraph (5) of this subdivision, shall not affect the
validity of an award.
(7) Any party may be represented in a master arbitration by an attorney.
20
(8) A master arbitration shall proceed if any party, after due notice of the
date to submit materials or date of oral arguments, fails to appear, to submit
materials or to obtain a postponement or adjournment. However, an award shall
not be made in favor of an appearing party solely on the default of another
party. A master arbitrator shall direct the appearing party to submit such
materials as may be required in order to render a decision in the matter.
(e) Award by master arbitrator. (1) Form and scope of award.
(i) The award shall be in writing in a format approved by the
superintendent. It shall state the issues in dispute and contain the master
arbitrator’s findings and conclusions based on the materials submitted. It
shall be signed by the master arbitrator and shall be transmitted to the
parties by the designated organization, with a copy to the Insurance
Department. The award shall be determinative of all issues submitted to the
master arbitrator by the parties.
(ii) If the applicant for benefits prevails in whole or part on the claim,
the award shall also direct the insurer to:
(a) if the applicant requested review by a master arbitrator, pay to
the applicant reimbursement of the amount of the master arbitration
filing fee paid;
(b) pay to the applicant the amount previously paid by the
applicant to reimburse for the filing fee in the arbitration below, unless
the filing fee had already been returned to the applicant pursuant to an
earlier award;
(c) if due under section 5106 of the Insurance Law, pay a
reasonable attorney’s fee in accordance with the limitations set forth in
subdivision (j) of this section;
(d) if due, compute and pay the amount of interest for each
element of first-party benefits in dispute, commencing 30 days after
proof of claim therefor was received by the insurer and ending with the
date of payment of the award, subject to the provisions of subdivision
65-3.10(c) of this Part (stay of interest).
(2) Award upon settlement. If the parties settle their dispute during the
course of the master arbitration, the master arbitrator shall set forth the terms of
the agreed settlement in an award which shall provide that the parties agree
that the settlement is final and binding and shall not be subject to review by a
court or the subject of a de novo court action. The award shall be signed by the
master and shall be transmitted to the parties by the designated organization,
with a copy to the Insurance Department.
(3) Delivery of award to parties. The parties shall accept as delivery of the
award the placing of the award or a true copy thereof in the mail, addressed to
the parties or their designated representatives at their last known addresses, or
21
by any other form of service permitted by law. The designated organization shall
note on such award or transmittal letter thereof the date of mailing and keep a
record of same.
(4) Payment of award. Subject to subdivision (h) of this section, the insurer
shall, within 21 calendar days of the date of mailing of the award, pay the
amounts set forth in the award. The award need not be confirmed into
judgment.
(f) Interpretation and application of procedures. The master arbitrator shall
interpret and apply the procedures of this section insofar as they relate to the master
arbitrator’s powers and duties. All other procedures shall be administered by the
designated organization, subject to consultation with and approval by the
superintendent.
(g) Alternative legal remedies. The designated organization or the master
arbitrator shall transmit to the superintendent copies of any legal papers served
upon the designated organization, or the master arbitrator, relating to any stay or
appeal of a master arbitration.
(h) Appeal from master arbitrators award. (1) A decision of a master arbitrator
is final and binding, except for:
(i) court review pursuant to an article 75 proceeding; or
(ii) if the award of the master arbitrator is $5,000 or greater,
exclusive of interest and attorney’s fees, either party may, in lieu of an
article 75 proceeding, institute a court action to adjudicate the dispute de
novo.
(2) A party who intends to commence an article 75 proceeding or an action
to adjudicate a dispute de novo shall follow the applicable procedures as set
forth in CPLR article 75. If the party initiating such action is an insurer, payment
of all amounts set forth in the master arbitration award which will not be the
subject of judicial action or review shall be made prior to the commencement of
such action.
(i) Master arbitrator’s fee. The master arbitrator shall be compensated in the
amount of $250 for each case. Such fee will be paid by the designated organization.
The master arbitrator’s fee shall be charged to the cost of administering the master
arbitration system.
(j) Limitations on attorney’s fees pursuant to section 5106 of the Insurance
Law. The following limitations shall apply to the payment by insurers of applicant’s
attorney’s fees for services rendered in a master arbitration to resolve a no-fault
dispute:
(1) The minimum attorney’s fee payable pursuant to this subpart shall be
$60.
22
(2) (i) For preparatory services necessarily rendered, the attorney shall be
entitled to receive a fee of up to $65 per hour, subject to a maximum fee of
$650.
(ii) An attorney shall be entitled to receive a fee of up to $80 per hour
for oral argument before the master arbitrator, made pursuant to paragraph
(c)(1) of this section.
(iii) If an applicant is successful in obtaining a reversal of the
arbitration(s) below, wherein no attorney’s fee was awarded, the attorney in
the arbitration below shall also be entitled to receive a fee, computed in
accordance with the provisions of section 65-4.6 of this Subpart.
(3) Notwithstanding the above limitations, if the master arbitrator
determines that the issues in dispute were of such a novel or unique nature as
to require extraordinary skills or services, the master arbitrator may award an
attorney’s fee in excess of the limitations set forth above. An excess fee award
shall detail the specific novel or unique nature of the dispute which justifies the
award.
(4) The attorney’s fee for services rendered in connection with a court
adjudication of a dispute de novo, as provided in section 5106(c) of the
Insurance Law, or in a court appeal from a master arbitration award and any
further appeals, shall be fixed by the court adjudicating the matter.
(5) No attorney shall demand, request or receive from the insurer any
payment or fee in excess of the fees permitted by this subdivision for services
rendered with respect to a no-fault master arbitration dispute.
(k) Financing. (1) The cost of administering the master arbitration system over
and above the amount of fees paid by applicants and insurers shall be paid
annually by insurers to the designated organization upon receipt of a statement
therefrom. This cost shall be distributed among insurers in an equitable manner
approved by the superintendent. This distribution shall, to the extent practicable,
be a function of the degree to which an insurer is a party to arbitration
proceedings.
(2) Upon filing of a demand for master arbitration by an applicant, the
designated organization shall bill the respondent insurer the sum of $250, which
shall be payable by the insurer within 30 days after billing.
(3) On an annual basis, as of December 31
st
of each year, the designated
organization shall prepare a detailed accounting of the actual costs incurred for
the implementation of the master arbitration system and the amount of fees
received from applicants and insurers. The accounting will be forwarded to the
No-Fault Optional Arbitration Advisory Committee (the committee) and the
superintendent on or before April 30
th
of each year. The committee shall notify
the designated organization and the superintendent whether it accepts the
designated organization’s accounting in whole or in part. In the event the
designated organization and the committee cannot resolve any differences that
23
may exist, the dispute will be referred to the superintendent for resolution. The
superintendent’s decision shall be binding on the designated organization and
insurers.
(4) Once the designated organization submits a final accounting that has
either been approved by the committee or resolved, in the event of a dispute, by
the superintendent, the designated organization shall send to each insurer a bill
for the amount due or a refund for the amount credited, based upon the number
of master arbitrations to which the insurer was a party.
65-4.11 Mandatory arbitration for insurers, self-insurers and
compensation providers under section 5105 of the Insurance Law. (a)
Applicability. (1) This section shall apply to mandatory arbitration of
controversies between insurers, pursuant to the provisions of section 5105 of
the Insurance Law, and shall apply to insurers, self-insurers and compensation
providers. The term insurer as used in this section (except as specified in
paragraphs (c)(2) and (f)(1) of this section) shall include both “insurers” and
“self-insurers” as those terms are defined in this Part and article 51 of the
Insurance Law; the Motor Vehicle Accident Indemnification Corporation
(MVAIC); any company providing insurance pursuant to section 5103(g) of the
Insurance Law; and compensation providers as defined in section 5102(l) of the
Insurance Law.
(2) All insurers shall submit controversies arising out of accidents, insured
events or occurrences within the jurisdiction of section 5105 or 5221(b) of the
Insurance Law to mandatory arbitration, as prescribed in this section.
Controversies arising from accidents, insured events or occurrences outside the
jurisdiction of section 5105 or 5221(b) may be submitted with the consent of the
controverting insurers.
(3) Any determination as to whether an insurer is legally entitled to
recovery from another insurer shall be made by an arbitration panel (see
paragraph (c)(2) of this section) appointed pursuant to this section. The
decision of a majority of an arbitration panel shall be final and binding upon the
insurers to the controversy. There shall be no right of rehearing or appeal.
However, this provision does not preclude correction of clerical or typographical
errors.
(4) Where arbitrating insurers are signators to any insurer arbitration
program under which a claim or companion claims would be otherwise subject
to the compulsory jurisdiction of such agreements, the jurisdiction of this section
shall be primary. Insurers shall waive their rights to proceed separately under
such other arbitration programs and include all claims arising out of the same
accident or insured event for disposition by an arbitration panel appointed
pursuant to this section.
(5) This section is applicable only to controversies involving insurers.
(6) Other than claims asserted by MVAIC against an insurer, this section
shall not apply to any claim for recovery rights to which an insurer in good faith
24
asserts a defense of lack of coverage of an alleged covered person on any
grounds, unless specific written consent of mandatory arbitration is obtained
from the insurer asserting such defense. Where an insurer asserts a defense of
lack of coverage of an alleged covered person on any grounds relating to claims
asserted by MVAIC for recovery rights, same shall be subject to mandatory
arbitration. However, any controversy between insurers involving the
responsibility or the obligation to pay first-party benefits (i.e., priority or payment
or sources of payment as provided in section 65-3.12 of this Part) is not
considered a coverage question and must be submitted to mandatory arbitration
under this section.
(7) This section shall not be construed to create any causes of action or
liabilities not existing in law or equity, nor shall this section be construed to
abolish any causes of action or liabilities existing in law or equity.
(b) Administration of arbitration. (1) The arbitration prescribed in this section
shall be administered by an Inter-Company Arbitration administrator
“Administrator” designated by the Superintendent. The Administrator may:
(i) make appropriate administrative rules for arbitrations;
(ii) select places where arbitration facilities are to be available, and
adopt a policy for the selection and appointment of arbitration panels; and
(iii) make appropriate recommendations for equitable apportionment
among arbitrating insurers of the operating expenses of this program.
(2) Local arbitration panels. (i) Members of local arbitration panels shall be
appointed by the Administrator from full-time salaried representative of insurers,
on the basis of their experience and qualifications, and shall serve without
compensation.
(ii) The Administrator shall be responsible for the selection of
arbitration panels to hear the particular cases.
(c) Selection of arbitrators. (1) Insurers shall furnish the Administrator with a list
of names, titles and local addresses of all employees who are qualified to act as
arbitrators.
(2) The Administrator shall designate one disinterested member of such
panel to serve as an arbitrator in each case. However, an insurer may request a
three-member arbitration panel in a specific case. If one or more of the
controverting parties is a self-insurer which has requested a three-member
panel, then the self-insurer may also request that at least one member of the
panel be a disinterested representative of a self-insurer, where such
representative is available to serve on the panel.
(3) No one shall serve as an arbitrator on a panel hearing a case in which
the insurer represented by the arbitrator is directly or indirectly interested.
25
(d) All arbitrations under this Subpart shall be conducted in accordance with
procedures established by the Administrator and approved by the superintendent.
(e) Filing assessments. (1) The Administrator, by resolution, will recommend
the filing assessment for the use of local arbitration facilities. The expenses
of the program shall be periodically reviewed by the loss transfer advisory
committee (see subdivision (f) of this section), which shall consider the
recommendations of the Administrator and prescribe from time to time
arbitration assessments.
(2) The obligation for the prescribed filing assessment is incurred
upon filing by the applicant, by a respondent filing a counterclaim or by a
party filing a deferment. There are no exceptions to an insurer’s obligation
to pay the filing assessment.
(3) The secretary of the Administrator is the custodian of the
assessment charges collected and shall make expenditures therefrom to
defray such arbitration expenses as may be authorized by the Administrator.
(4) The secretary of the Administrator will submit reports on
assessments collected and disbursed during such period as may be
considered desirable by the Administrator.
(f) Loss transfer advisory committee. (1) The superintendent shall select a loss
transfer advisory committee composed of 14 members, of which eight shall
represent motor vehicle insurers, three shall represent motor vehicle self-
insurers, two shall represent compensation providers and one shall
represent the Motor Vehicle Accident Indemnification Corporation.
(2) The loss transfer advisory committee shall:
(i) regularly review the operations, procedures, rules,
expenditures, assessments and all other relevant matters involving
settlements between insurers in accordance with the requirements of
section 5105 or 5221(b) of the Insurance Law;
(ii) review the operations of the Administrator insofar as they
relate to the arbitration prescribed in this section; and
(iii) report its findings, conclusions and recommendations directly
to the superintendent annually and at such other intervals as it deems
appropriate.
I, Gregory V. Serio, Superintendent of Insurance, do hereby certify that the
foregoing is the new Part 11 NYCRR 65 (Regulation 68), promulgated by me on July
25, 2001 pursuant to the authority granted by Sections 201, 301, 2601, 5221 and
Article 51 of the Insurance Law and Section 2407 of the Vehicle and Traffic Law, to
take effect on September 1, 2001, after publication in the State Register.
26
Pursuant to the provisions of the State Administrative Procedure Act, prior
notice of the proposed regulation was published in the State Register on August 2,
2000, notice of continuation of the proposed regulation was published in the January
17, 2001 issue of the State Register and notice of the revised proposed regulation
was published in the May 9, 2001 issue of the State Register. No other publication
or prior notice is required by statute.
Gregory V. Serio
Superintendent of Insurance
July 25, 2001
APPENDIX 13
(cf. Part 65)
PRESCRIBED NO-FAULT FORMS
The previous Appendices 13, which had been applicable to claims arising from accidents
that occurred prior to December 1, 1977, 13-A and 13-B, which had been applicable to claims
arising from accidents that occurred after December 1, 1977, have been deleted and replaced
by the following Appendix 13.
The forms contained herein have been reduced in size for convenience of promulgation.
The forms must be reprinted in a size and format using type which is clear and readable and
which allows sufficient space to facilitate the completion of the information requested therein.
Except for the Cover Letter (NYS Form NF-1), which must be supplied to all eligible injured
persons to whom the new notice requirements will be applied, insurers may continue to use
supplies of the existing No-Fault claim forms until December 1, 2001. However, the revised
fraud warning statement contained herein must be affixed thereon by use of a label or any
appropriate attachment.
2
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
NAME AND ADDRESS OF INSURER OR SELF-INSURER
PHONE NUMBER OF REPRESENTATIVE
NAME AND ADDRESS OF INSURER
NAME AND PHONE NUMBER OF
CLAIM REPRESENTATIVE
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT COMPLETE THE ATTACHED DB-450 FORM
IMMEDIATELY IF YOU ARE ENTITLED TO NEW
YORK STATE DISABILITY BENEFITS AND MAIL
OR GIVE IT TO YOUR EMPLOYER. TO FIND OUT
IF YOU ARE ELIGIBLE, TELEPHONE THE NEW
YORK STATE DISABILITY BENEFITS BUREAU AT
(718) 802-6964
DEAR APPLICANT:
This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New York No-Fault Law
provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for their basic economic loss. Briefly summarized,
basic economic loss consists of up to $50,000 per person in benefits for the following:
a. all necessary doctor and hospital bills and other health service expenses, payable in accordance with
fee schedules established or adopted by the New York State Insurance Department;
b. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the
date of the accident;
c. up to $25 per day for a period of one year from the date of the accident for other reasonable and
necessary expenses the injured person may have incurred because of an injury resulting from the
accident, such as the cost of hiring a housekeeper or necessary transportation expenses to and from
a health service provider; and
d. a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000
coverage for economic loss described above.
Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss coverage and/or
Additional Personal Injury Protection coverage.
In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the accident from Workers'
Compensation, New York State Disability, and certain wage continuation plans will reduce your No-Fault benefits. Therefore, if you are entitled
to any of these benefits you should make your claim for them promptly.
If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL coverage, you may be entitled
to an additional $25,000 of Basic Economic Loss coverage. You should make your claim to that motor vehicle insurer promptly, but in no event
later than 90 days after your $50,000 of Basic Economic Loss coverage under this policy is exhausted.
NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must be paid by your
auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further provides that you should only file a No-
Fault claim with us if there is no such auto policy in your household. The above rule does not apply and you may file a No-Fault claim with us if
you are the operator, owner or employee of the owner of the bus company.
NYS FORM NF-1A (Rev9/2001)
3
COVER LETTER -- PAGE TWO
To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you have
received to date. This application must be received by us within 30 days of the accident date if your original notice to us was not
in writing.
You are entitled to receive health service benefits without any time limit if it is possible to determine during the first year
that after the accident that further health services may be required after the first year. As you receive additional medical
bills or any other bills you believe to be covered, send them to us immediately. In order to be considered for payment, all
bills for health care services must be submitted within 45 days of treatment. If it is not possible for you or your health care
provider to submit these bills within that time period, submit a written explanation of the reason for the delay. Claims for
lost earnings and other reasonable and necessary expenses must be submitted within 90 days. We will reimburse you as
soon as we are able to verify that they are covered expenses under No-Fault. Please identify all communications with us
with the claim number shown above. Should you have any questions concerning your claim, we will be most happy to
assist you. Please feel free to call us at the above phone number.
PLEASE NOTE THAT THE TIME ALLOWED FOR PROVIDING NOTICE AND PROOF OF CLAIM TO YOUR INSURER HAS
BEEN
REDUCED. FAILURE TO RETURN A COMPLETED APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
FORM (NF-2) TO YOUR INSURER TIMELY CAN RESULT IN LOSS OF ALL BENEFITS. FAILURE TO SUBMIT BILLS FOR
HEALTH CARE SERVICES WITHIN 45 DAYS OF TREATMENT OR MAKE CLAIM FOR LOST EARNINGS OR OTHER
REASONABLE AND NECESSARY EXPENSES WITHIN 90 DAYS OF OCCURRENCE CAN RESULT IN THOSE BENEFITS
BEING DENIED. If your insurer denies coverage for failure to make a timely submission you can provide them with a written
reply stating why you could not reasonably meet the time frames and your insurer must consider it.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE
CLAIM FOR EACH SUCH VIOLATION.
Very truly yours,
____________________________________
IMPORTANT REMINDERS
PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH
AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM.
NYS FORM NF-1A (Rev
9/2001)
4
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
NAME AND ADDRESS OF INSURER OR SELF-INSURER
PHONE NUMBER OF REPRESENTATIVE
NAME AND ADDRESS OF INSURER
NAME AND PHONE NUMBER OF
CLAIM REPRESENTATIVE
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT COMPLETE THE ATTACHED DB-450 FORM
IMMEDIATELY IF YOU ARE ENTITLED TO NEW
YORK STATE DISABILITY BENEFITS AND MAIL
OR GIVE IT TO YOUR EMPLOYER. TO FIND OUT
IF YOU ARE ELIGIBLE, TELEPHONE THE NEW
YORK STATE DISABILITY BENEFITS BUREAU AT
(718) 802-6964
DEAR APPLICANT:
This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New York No-Fault Law
provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for their basic economic loss. Briefly summarized,
basic economic loss consists of up to $50,000 per person in benefits for the following:
a. all necessary doctor and hospital bills and other health service expenses, payable in accordance with
fee schedules established or adopted by the New York State Insurance Department;
b. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the
date of the accident;
c. up to $25 per day for a period of one year from the date of the accident for other reasonable and
necessary expenses the injured person may have incurred because of an injury resulting from the
accident, such as the cost of hiring a housekeeper or necessary transportation expenses to and from
a health service provider; and
d. a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000
coverage for economic loss described above.
Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss coverage and/or
Additional Personal Injury Protection coverage.
In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the accident from Workers'
Compensation, New York State Disability, and certain wage continuation plans will reduce your No-Fault benefits. Therefore, if you are entitled
to any of these benefits you should make your claim for them promptly.
If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL coverage, you may be entitled
to an additional $25,000 of Basic Economic Loss coverage. You should make your claim to that motor vehicle insurer promptly, but in no event
later than 90 days after your $50,000 of Basic Economic Loss coverage under this policy is exhausted.
NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must be paid by your
auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further provides that you should only file a No-
Fault claim with us if there is no such auto policy in your household. The above rule does not apply and you may file a No-Fault claim with us if
you are the operator, owner or employee of the owner of the bus company.
NYS FORM NF-1B (Rev 9/2001)
5
COVER LETTER -- PAGE TWO
To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you have
received to date. This application must be received by us within 90 days of the accident date if your original notice to us was not
in writing.
You are entitled to receive health service benefits without any time limit if it is possible to determine during the first year
that after the accident that further health services may be required after the first year. As you receive additional medical
bills or any other bills you believe to be covered, send them to us immediately. In order to be considered for payment, all
bills for health care services must be submitted within 180 days of treatment. If it is not possible for you or your health
care provider to submit these bills within that time period, submit a written explanation of the reason for the delay. Claims
for other reasonable and necessary expenses must be submitted within 90 days. We will reimburse you as soon as we
are able to verify that they are covered expenses under No-Fault. Please identify all communications with us with the
claim number shown above. Should you have any questions concerning your claim, we will be most happy to assist you.
Please feel free to call us at the above phone number.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE
CLAIM FOR EACH SUCH VIOLATION.
Very truly yours,
____________________________________
IMPORTANT REMINDERS
PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH
AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM.
NYS FORM NF-1B (Rev 9
/2001)
6
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
NAME AND ADDRESS OF INSURER
*
NAME, ADDRESS, AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
TO ENABLE US TO DETERMINE IF YOUR ARE ENTITLED TO BENEFITS UNDER THE NEW YORK NO-FAULT LAW, PLEASE COMPLETE THIS FORM AND
RETURN IT PROMPTLY.
IMPORTANT: 1. TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION.
2. YOU MUST SIGN ANY ATTACHED AUTHORIZATION(S).
3. RETURN PROMPTLY WITH COPIES OF ANY BILLS YOU HAVE RECEIVED TO DATE.
NAME AND ADDRESS OF APPLICANT
*
1. YOUR NAME
2. PHONE NOS. HOME BUSINESS
3. YOUR ADDRESS (NO., STREET, CITY OR TOWN AND ZIP CODE)
4. DATE OF BIRTH 5. SOCIAL SECURITY NO.
6. DATE AND TIME OF ACCIDENT A.M.
P.M.
7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE
8. BRIEF DESCRIPTION OF ACCIDENT:
9. DESCRIBE YOUR INJURY:
10. IDENTITY OF VEHICLE YOU OCCUPIED OR
OPERATED AT THE TIME OF THE ACCIDENT:
OWNER'S NAME MAKE YEAR
THIS VEHICLE WAS:________A BUS OR SCHOOL BUS
_______A TRUCK, OR_______AN AUTOMOBILE
_______A MOTORCYCLE
11. WERE YOU THE DRIVER OF THE MOTOR
VEHICLE?
WERE YOU A PASSENGER IN THE MOTOR
VEHICLE?
WERE YOU A PEDESTRIAN?
WERE YOU A MEMBER OF OUR POLICY-
HOLDER’S HOUSEHOLD?
DO YOU OR A RELATIVE WITH WHOM
YOU RESIDE OWN A MOTOR VEHICLE?
__YES __NO
__YES __NO
__YES __NO
__YES __NO
__YES __NO
12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES? __YES __NO
NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S):
13. IF YOUR WERE TREATED AT A HOSPITAL(S), WERE YOU AN OUT-PATIENT?____ IN-PATIENT____
DATE OF ADMISSION: HOSPITAL'S NAME AND ADDRESS:
14. AMOUNT OF HEALTH BILLS
TO DATE $____________
15. WILL YOU HAVE MORE
HEALTH TREATMENT(S)
___YES ___NO
16. AT THE TIME OF YOUR ACCIDENT
WERE YOU IN THE COURSE OF
YOUR EMPLOYMENT? ___YES ___NO
17. DID YOU LOSE TIME
FROM WORK?
__YES __NO
DATE ABSENCE FROM
WORK BEGAN:
HAVE YOU RETURNED
TO WORK?
__YES __NO
IF YES, DATE RETURNED TO
WORK:
AMOUNT OF TIME LOST FROM WORK: 18. WHAT ARE YOUR AVERAGE
WEEKLY EARNINGS?
NUMBER OF DAYS YOU
WORK PER WEEK:
NUMBER OF HOURS YOU
WORK PER DAY:
19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS
AT THE TIME OF THE ACCIDENT? __YES __NO
CONTINUATION ON NEXT PAGE
NYS FORM NF-2
7
20. LIST NAMES AND ADDRESS OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO ACCIDENT DATE AND GIVE
OCCUPATION AND DATES OF EMPLOYMENT:
EMPLOYER AND ADDRESS OCCUPATION FROM TO
EMPLOYER AND ADDRESS OCCUPATION FROM TO
EMPLOYER AND ADDRESS OCCUPATION FROM TO
21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES NO
IF YES, ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES.
22. DUE TO THIS ACCIDENT HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR PAYMENTS
UNDER ANY OF THE FOLLOWING:
NEW YORK STATE DISABILITY? WORKERS' COMPENSATION?
YES NO YES NO
THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF SUCH IS NECESSARY
TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THE NO-FAULT LAW.
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE
APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
SIGNATURE:____________________________________________________DATE:__________________________
. . . . . . . . . . . . .
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF WORK
AND OTHER LOSS INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES,
SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOUR ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW
YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW)
NAME (PRINT OR TYPE) SOCIAL SECURITY NO.
SIGNATURE DATE
. . . . . . . . . . . . . . .
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF HEALTH
SERVICE OR TREATMENT INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION
WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND
PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE
INSURANCE REPARATIONS ACT (NO-FAULT LAW)
NAME (PRINT OR TYPE)
SIGNATURE DATE
(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP).
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-2 (Rev9/2001
)
8
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
(This form is not
for verification of hospital treatment )
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
*
NAME OF INSURER’S CLAIMS REPRESENTATIVE
ADDRESS OF REPRESENTATIVE
PHONE NUMBER OF REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
PROVIDER’S NAME AND ADDRESS
*
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST
BE SUBMITTED TO INSURER NO LATER THAN 45 DAYS AFTER TREATMENT DATE.
IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY CHANGES FROM THE
INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.
1. PATIENT’S NAME AND ADDRESS
2. AGE
3. SEX 4. OCCUPATION (IF KNOWN)
5. DIAGNOSIS AND CONCURRENT CONDITIONS
6: WHEN DID SYMPTOMS FIRST APPEAR?
DATE:
7. WHEN DID PATIENT FIRST CONSULT YOU FOR THIS
CONDITION? DATE:
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION
YES NO IF “YES”, state when and describe:
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
YES NO IF “NO”, explain:
10. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT’S EMPLOYMENT?
YES NO
11. WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY?
YES NO NOT DETERMINABLE AT THIS TIME
IF “YES”, DESCRIBE:
12. PATIENT WAS DISABLED (UNABLE TO WORK)
FROM: THROUGH:
13. IF STILL DISABLED THE PATIENT SHOULD BE ABLE
TO RETURN TO WORK ON: (DATE)
CONTINUE ON PAGE 2
* Bracketed language to be filled in by insurer or self-insurer
NYS FORM NF-3
9
PAGE 2
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
14. WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE
INJURIES SUSTAINED IN THIS ACCIDENT?
YES NO IF "YES", DESCRIBE YOUR RECOMMENDATION BELOW:
15. REPORT OF SERVICES RENDERED
DATE OF
SERVICE
PLACE OF SERVICE
INCLUDING ZIP CODE
DESCRIPTION OF TREATMENT OR
HEALTH SERVICE RENDERED
FEE SCHEDULE
TREATMENT CODE
CHARGES
TOTAL CHARGES TO DATE $
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING:
TREATING PROVIDER’S
NAME
TITLE LICENSE OR
CERTIFICATION NUMBER
BUSINESS RELATIONSHIP
CHECK APPLICABLE BOX
EMPLOYEE
INDEPENDENT
CONTRACTOR
OTHER (SPECIFY)
17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME (DBA),
LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Provide an additional attachment if necessary).
18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? YES NO
19. ESTIMATED DURATION OF FUTURE TREATMENT
20. INJURED OR AUTHORIZED PERSON’S SIGNATURE: OPTIONAL
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES DESCRIBED
BELOW.
SIGNED________________________________________________________________________
21. ASSIGNMENT OF NO-FAULT BENEFITS: SIGNATURE OPTIONAL
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED
UNDER ARTICLE 51 (THE NO-FAULT PROVISION) OF THE INSURANCE LAW. ANY PAYMENT PURSUANT TO THIS ASSIGNMENT SHALL NOT
EXCEED THE HEALTH CARE PROVIDER’S PERMISSABLE CHARGES UNDER SAID ARTICLE 51.
SIGNED________________________________________________________________________
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
DATE PROVIDER'S SIGNATURE IRS/TIN IDENTIFICATION NO. WCB RATING CODE
IF NONE, SPECIALTY
INSURER LIST ADDITIONAL VERIFICATION REQUIRED: ADD SEPARATE PAGE IF NECESSARY *
1.
2.
3.
*Bracketed language to be filled in by insurer or self-insurer
NYS FORM NF-3 (Rev9/2001)
10
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF HOSPITAL TREATMENT
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
*
NAME ADDRESS AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF HOSPITAL
*
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST BE
SUBMITTED TO INSURER NO LATER THAN 45 DAYS AFTER TREATMENT DATE.
1. PATIENT'S NAME
2. DATE OF BIRTH
3. PATIENT'S ADDRESS
4. DATE ADMITTED 5. TIME ADMITTED
A.M. P.M.
6. DATE DISCHARGED 7. TIME DISCHARGED
A.M. P.M.
8. a. ADMITTING DIAGNOSIS:
b. DISCHARGE DIAGNOSIS:
9. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT'S EMPLOYMENT? __YES ___NO
10. OPERATIONS OR PROCEDURES PERFORMED (NATURE AND DATES):
11. WAS TREATMENT RENDERED SOLELY AS A RESULT OF THE ABOVE ACCIDENT? __ YES __ NO
IF "NO" PLEASE EXPLAIN
12. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? __ YES __ NO
IF "YES" PLEASE EXPLAIN AND INDICATE DURATION
13. REPORT OF SERVICES RENDERED
HOSPITAL CHARGES MUST BE COMPUTED IN ACCORDANCE WITH RATES PERMITTED BY SECTION 5108 OF THE NEW YORK
INSURANCE LAW AND INSURANCE DEPARTMENT REGULATION NO. 83.
14. INJURED OR AUTHORIZED PERSON’S SIGNATURE: OPTIONAL
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE HOSPITAL, HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES AS DESCRIBED
ON THE ATTACHED ITEMIZED BILL
SIGNED_________________________________________________________________________________.
15. ASSIGNMENT OF NO-FAULT BENEFITS: SIGNATAURE OPTIONAL
I HEREBY ASSIGN TO THE HOSPITAL AND OR HEALTH CARE PROVIDER ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM
ENTITLED UNDER ARTICLE 51 (THE NO-FAULT PROVISIONS) OF THE INSURANCE LAW. ANY PAYMENT PURSUANT TO THIS ASSIGNMENT
SHALL NOT EXCEED THE HEALTH CARE PROVIDER’S PERMISSABLE CHARGES UNDER SAID ARTICLE 51.
SIGNED________________________________________________________________________________
DESCRIBE AND ATTACH ITEMIZED BILL
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
TAKEN BY: _________________________________________________________________________________________________________
(SIGNATURE) (TITLE) (PHONE NO. & EXT.)
INSURER LIST ADDITIONAL VERIFICATION REQUIRED: ADD SEPARATE PAGE IF NECESSARY *
1.
2.
3.
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF INSURER
NYS FORM NF-4
(Rev9/2001)
11
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
HOSPITAL FACILITY FORM
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST
BE SUBMITTED TO INSURER NO LATER THAN 45 DAYS AFTER TREATMENT DATE.
1. INSURANCE COMPANY
2. PATIENT'S NAME 3. BIRTH DATE
4. ADDRESS OF INSURANCE COMPANY
5. PATIENT'S ADDRESS 6. PHONE NUMBER
7. AUTOMOBILE POLICY NUMBER
8. NAME OF POLICYHOLDER
9. ACCIDENT DATE
10. ADMISSION
DATE
11. ADDRESS OF POLICYHOLDER
12. DISCHARGE DATE 13 . PLACE OF ACCIDENT
14. DESCRIPTION OF ACCIDENT
15. IDENTITY OF VEHICLE OCCUPIED OR
OPERATED AT THE TIME OF THE ACCIDENT
WAS PATIENT THE DRIVER OF THE MOTOR VEHICLE? __YES __NO
OWNER’S NAME MAKE YEAR
WAS PATIENT A PASSENGER IN THE MOTOR VEHICLE? __YES __NO
WAS PATIENT A PEDESTRIAN? __YES __NO
WAS PATIENT A MEMBER OF THE POLICYHOLDERS
HOUSEHOLD?
__YES __NO
THIS VEHICLE WAS: A BUS OR SCHOOL BUS AN AUTOMOBILE A MOTORCYCLE A TRUCK
16. A. ADMITTING DIAGNOSIS:
B. DISCHARGE DIAGNOSIS:
17. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT'S EMPLOYMENT? __YES ___NO
18. WAS TREATMENT RENDERED SOLELY AS A RESULT OF INJURIES ARISING OUT OF
THE ABOVE ACCIDENT?
__ YES __ NO IF "NO" PLEASE EXPLAIN
19. OPERATIONS OR PROCEDURES PERFORMED (NATURE AND DATE):
20. REPORT OF SERVICES RENDERED HOSPITAL CHARGES MUST BE COMPUTED IN ACCORDANCE WITH RATES
PERMITTED BY SECTION 5108 OF THE NEW YORK INSURANCE LAW AND
INSURANCE DEPARTMENT REGULATION NO. 83.
DESCRIBE AND ATTACH ITEMIZED BILL.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
TAKEN BY: _____________________________________________________________________________________________________
(SIGNATURE) (TITLE) (PHONE NO. & EXT.)
__________________________________
DATE TAKEN FROM RECORDS
CONTINUED ON PAGE 2
INSURER LIST ADDITIONAL VERIFICATION REQUIRED: ADD SEPARATE PAGE IF NECESSARY *
1.
2.
3.
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF INSURER
NYS FORM NF-5 (Rev9/2001)
12
HOSPITAL FACILITY FORM
PAGE 2
THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF SUCH IS NECESSARY
TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THIS ACT.
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE PATIENT AS TRUE UNDER THE PENALTIES OF PERJURY.
SIGNATURE: DATE:
(PATIENT, PARENT OR GUARDIAN)
DO NOT DETACH
ASSIGNMENT*
SIGNATURE OF PATIENT, PARENT OR GUARDIAN DATE
*ATTACH OR INSERT ASSIGNMENT WHICH SHALL BE LIMITED TO THE AMOUNT CLAIMED
BY THE HOSPITAL FOR SERVICES DESCRIBED ON THIS FORM.
NYS FORM NF-5 (Rev9/2001
)
- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - - - -- - - - - -
AUTHORIZATION FOR RELEASE OF HEALTH SERVICE
OR TREATMENT INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY
CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICAL FINDINGS,
DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK
COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).
SIGNATURE OF PATIENT, PARENT OR GUARDIAN DATE
NYS FORM NF-5 (Rev9/2001)
13
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
EMPLOYER’S WAGE VERIFICATION REPORT
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
*
NAME, ADDRESS AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF EMPLOYER
*
EMPLOYEE’S NAME AND ADDRESS
SOCIAL SECURITY NO.
*
DEAR EMPLOYER:
The above named person has applied for benefits under the NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT
LAW) as a result of injuries sustained in a motor vehicle accident on the date indicated. We understand this person is your employee or former employee. To assist us in
determining benefits that may be due the applicant, please provide us with the answer to the following questions.
PLEASE COMPLETE AND SUBMIT THIS FORM TO OUR CLAIMS REPRESENTATIVE AS SOON AS POSSIBLE . PLEASE NOTE
COMPLETED FORM MUST BE SUBMITTED TO INSURER NO LATER THAN 90 DAYS AFTER WORK LOSS WAS FIRST INCURRED.
Thank you for your cooperation.
CLAIM REPRESENTATIVE
1. EMPLOYEE'S OCCUPATION:
2. DATES OF EMPLOYMENT: FROM
THROUGH:
3. GROSS EARNINGS DURING 52 WEEK PERIOD PRIOR TO ACCIDENT: $
WAGE OR SALARY AS OF DATE OF ACCIDENT: $
HOURLY WEEKLY MONTHLY
NUMBER OF HOURS NORMALLY WORKED PER DAY
_____NUMBER OF DAYS NORMALLY WORKED PER WEEK _____
4. DATES ABSENT FOLLOWING ACCIDENT:
FIRST DAY ABSENT FROM WORK
DATE RETURNED TO WORK
5. HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE BENEFITS UNDER
ANY WORKERS' COMPENSATION LAW AS A RESULT OF THIS ACCIDENT? ____YES ___NO ___UNDETERMINED
WORKER'S COMPENSATION INSURER
ADDRESS
POLICY NUMBER
6. HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE NEW YORK STATE
DISABILITY BENEFITS AS A RESULT OF THIS ACCIDENT?
YES NO UNDETERMINED
IS THE EMPLOYEE REQUIRED TO PAY FOR DBL COVERAGE THROUGH PAYROLL DEDUCTION? ___YES ___NO
NYS DISABILITY INSURER
ADDRESS
POLICY NUMBER
7. WAS OR WILL EMPLOYEE BE PAID BY EMPLOYER FOR THIS ABSENCE FROM WORK?
YES ___NO
IF ANSWER TO QUESTION 7 IS "YES" PLEASE ANSWER QUESTIONS 8, 9, 10 and 11.
8. HOW MUCH WAS OR WILL EMPLOYEE BE PAID $
WEEKLY $ MONTHLY.
9. WILL THE EMPLOYEE BE REQUIRED TO REIMBURSE YOU ANY OF THE ABOVE AMOUNT? _____YES ___NO
10. WILL THE EMPLOYEE LOSE ACCUMULATED LEAVE CREDITS AS A RESULT OF THE FOREGOING PAYMENT?
_______YES
NO
11. WILL THE EMPLOYEE'S ELIGIBILITY FOR FUTURE WAGE BENEFITS BE AFFECTED BY PAYMENTS INDICATED
IN QUESTION 8 ABOVE?
YES NO
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
PRINT
NAME
SIGNED TITLE
TELEPHONE NUMBER
EXT. FEDERAL EMPLOYER I.D. NO. DATE____________
INSURER LIST ADDITIONAL VERIFICATION REQUIRED: ADD SEPARATE PAGE IF NECESSARY *
1.
2.
3.
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER
NYS FORM NF-6 (Rev9/2001
)
14
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF SELF-EMPLOYMENT INCOME
NAME AND ADDRESS
OF INSURER OR SELF-
INSURER
*
NAME, ADDRESS AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT
*
DEAR APPLICANT:
The information requested below will be used to determine the amount of loss of earnings from work, if any, to which you may be entitled as a
result of this accident. Therefore, it would be in your best interest to complete the form and submit all documents requested to the best of your
ability. PLEASE NOTE COMPLETED FORM MUST BE SUBMITTED TO INSURER NO LATER THAN 90 DAYS AFTER WORK LOSS WAS
FIRST INCURRED
1. OCCUPATION
2. BUSINESS ADDRESS
3. BUSINESS PHONE
4. NATURE OF BUSINESS OR PROFESSION
5. DATES YOU WERE UNABLE TO ATTEND TO YOUR BUSINESS OR PROFESSION DUE TO THIS ACCIDENT:
FROM:
THROUGH:
6. DID YOU HIRE ANY ONE TO SUBSTITUTE FOR YOU WHILE YOU WERE ABSENT DUE TO YOUR INJURIES YES No
If "YES", PLEASE COMPLETE THE FOLLOWING:
A. WAGE OR SALARY PAID: $
DAILY $ WEEKLY $ MONTHLY
B. PERIOD SUBSTITUTE EMPLOYED: FROM THROUGH
C. GROSS AMOUNT PAID TO SUBSTITUTE: $
D. NAME, ADDRESS AND PHONE NUMBER OF SUBSTITUTE:
7. IF ANSWER TO QUESTION 6, WAS "YES", DID YOU SUFFER A NET LOSS OF EARNINGS FROM WORK IN ADDITION
TO THE COST OF SUBSTITUTE SERVICES?
YES NO IF "YES", THE AMOUNT OF NET LOSS CLAIMED:$
FOR THE PERIOD
CLAIMED IN QUESTION 5.
8. IF ANSWER TO QUESTION 6. WAS "NO", DID YOU SUFFER A NET LOSS OF EARNINGS FROM WORK DURING YOUR
CLAIMED DISABILITY?
YES NO IF "YES", AMOUNT OF NET LOSS CLAIMED:$__________FOR THE PERIOD CLAIMED IN QUESTION 5.
9. IN ORDER FOR US TO EVALUATE YOUR CLAIM, IT IS ESSENTIAL THAT YOU SUBMIT COPIES OF YOUR FEDERAL
INCOME TAX RETURNS FOR THE LAST TWO YEARS. IN ADDITION, SUBMIT WHATEVER DOCUMENTS ARE AVAILABLE
TO PROVE YOUR INCOME FOR THE CURRENT YEAR. IF YOU HAVE NOT FILED EITHER OF THE TAX RETURNS, SUBMIT
WHATEVER PROOF OF EARNINGS YOU HAVE FOR THOSE YEARS THAT YOU FEEL WILL ASSIST US IN EVALUATING
YOUR CLAIM.
IF WE ARE UNABLE TO VERIFY YOUR LOSS OF EARNINGS FROM THE DOCUMENTS SUBMITTED, THE FOLLOWING ADDITIONAL
DOCUMENTATION MAY BE REQUESTED.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE
APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY
SIGNATURE OF APPLICANT
DATE
INSURER LIST ADDITIONAL VERIFICATION REQUIRED: ADD SEPARATE PAGE IF NECESSARY *
1.
2.
3.
*Bracketed language to be filled in by insurer or self-insurer.
NYS FORM NF-7 (Rev9/2001)
15
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
AGREEMENT TO PURSUE SOCIAL SECURITY DISABILITY BENEFITS
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
*
NAME, ADDRESS AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT
*
DEAR APPLICANT:
This three
part form must be completed by you and your district Social Security office in order for your No-Fault loss of earnings benefits
to continue without interruption.
I (NAME OF APPLICANT)
agree to apply for and diligently pursue within 35 days from the date above,
Social Security Disability benefits that may be recoverable on account of injuries caused by this accident.
The applicant further agrees to reimburse the Insurer for any amounts that may have been or may be advanced by the Insurer pursuant to this
agreement, pending receipt of Social Security Disability benefits. The applicant may deduct from the reimbursement any attorney's fee which
he/she paid in order to obtain the Social Security Disability benefits.
(NAME OF INSURER OR SELF-INSURER)
, upon receipt of this agreement and the Authorization for Release of Information by the Social
Security Administration, both duly signed by the Applicant or the Applicant's legal guardian, agrees to continue the payment of No-Fault benefits
for loss of earnings without deducting amounts recoverable as Social Security Disability benefits as permitted by Section 5102(b)(2) of the New
York Insurance Law, until such Social Security Disability benefits are received.
In the event that the applicant fails to sign and return this Agreement and Authorization or to apply for Social Security Disability benefits in
accordance with this Agreement within the aforesaid 35 day period, the insurer shall estimate the amount of monthly Social Security Disability
benefits which it believes the applicant would be entitled to receive and, beginning with the seventh month from the date of accident or 35
calendar days after the agreement was forwarded to the applicant, in the event the seventh month has passed, the insurer shall deduct the
estimated Social Security Disability benefits from loss of earnings benefits due on account of injuries caused by this accident to the applicant.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
____________
SIGNATURE OF APPLICANT DATE
_______________ _____________
SIGNATURE OF INSURER'S REPRESENTATIVE DATE
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER
NYS FORM NF-8
(Rev9/2001)
CONTINUED ON PAGE TWO
16
AGREEMENT TO PURSUE SOCIAL SECURITY DISABILITY BENEFITS
PAGE TWO
AUTHORIZATION FOR RELEASE OF INFORMATION BY THE SOCIAL SECURITY ADMINISTRATION
_________
_______________
NAME OF TITLE II CLAIMANT SOCIAL SECURITY CLAIM NUMBER
_______
______________
DATE APPLICANT'S SIGNATURE
I hereby authorize the Social Security Administration to disclose the necessary information, such as my name, account number, disability benefit
rate and date of entitlement to benefits to the person or agency listed below:
Disclose Information to:
______________________________
This authorization is effective for only as long as is needed to determine my eligibility to benefits and my rate of benefit payment.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
ATTENTION SOCIAL SECURITY CLAIMS REPRESENTATIVE!!
Please indicate below the resident D/O for the Disability Claim and the date filed. After doing so, place one copy of this authorization in file,
return two to the claimant and instruct the claimant to forward copy III to the Insurance Company.
_____
RESIDENT D/O DATE CLAIM FILED
COPY I-S.S.A
COPY II-APPLICANT
COPY III-INSURER
NYS FORM NF-8
(Rev9/2001)
17
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
AGREEMENT TO PURSUE WORKERS' COMPENSATION OR N.Y.S. DISABILITY BENEFITS
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
*
NAME, ADDRESS AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT
*
IT IS HEREBY AGREED between the Applicant and the Insurer, as follows:
In the event a source of Workers' Compensation or N.Y.S. Disability benefits denies liability for payment of benefits due on account of the
above accident, in whole or in part, the Insurer agrees to process the Applicant's No-Fault claim without deducting the withheld State or Federal
Workers' Compensation benefits or N.Y.S. Disability benefits under the following conditions:
FIRST: The Applicant executes this Agreement.
SECOND: In the event such amounts are eventually paid to the Applicant, the Applicant agrees to repay the first party benefits equal to
the withheld amounts of Workers' Compensation benefits or N.Y.S. Disability benefits less any attorney's fee which the Applicant paid in order to
obtain the benefits.
THIRD: In the event the Applicant does not reimburse the Insurer, as provided herein, the Insurer may thereafter deduct such amounts
from any future No-Fault benefits due the Applicant on the claim.
FOURTH: The Applicant agrees to diligently pursue any claim for Workers' Compensation or N.Y.S. Disability benefits.
FIFTH: In the event the Applicant fails to diligently pursue such claim for Workers' Compensation or N.Y.S. Disability benefits as set forth
in Paragraph Fourth or in the event the Applicant fails to reimburse the Insurer as provided herein, the Insurer may bring an action to recover the
amount paid under this agreement.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
DATE
SIGNATURE OF APPLICANT __________
DATE
SIGNATURE OF INSURER __________
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER
NYS FORM NF-9
(Rev9/2001)
18
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
DENIAL OF CLAIM FORM
(FOR PERSONAL INJURIES SUSTAINED ON AND AFTER 12/1/77)
TO INSURER: Complete this form, including item 31. Send 2 copies to applicant. Upon the request of the injured person, the insurer should send to the injured
person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person.
Name and address of insurer
or self-insurer
for Use By The American Arbitration AssociationOnly
A. POLICYHOLDER B. POLICY NUMBER C. DATE OF ACCIDENT D. INJURED PERSON
E. CLAIM NUMBER F. APPLICANT FOR BENEFITS (Name and Address) G. AS ASSIGNEE
1. Yes 2. No
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL
YOU ARE ADVISED THAT FOR REASONS NOTED BELOW:
1. Your entire claim is denied as follows:
2. A portion of your claim is denied as follows:
A. Loss of Earnings: $ D. Interest: $
B. Health Service Benefits: $ E. Attorney's Fees: $
C. Other Necessary Expenses: $ F. Death Benefit: $
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 30)
POLICY ISSUES
3. Policy not in force on date of accident: 6. Injured person not an "Eligible Injured Person":
4. Injured person excluded under policy conditions or exclusion:
5. Policy conditions violated
7. Injuries did not arise out of use or operation of a
motor vehicle
a. No reasonable justification given for late notice of claim.
b. Reasonable justification not established. You may qualify for
expedited arbitration. See back of this form for instructions.
8. Claim not within the scope of your election under
Optional Basic Economic Loss coverage
LOSS OF EARNINGS BENEFITS DENIED
9. Period of disability contested: period in dispute
From
Through
11. Exaggerated earnings claim
of $
per month denied
10. Claimed loss not proven: 12. Statutory offset taken
13. Other, explained below:
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
14. Amount of claim exceeds daily limit of coverage 16. Incurred after one year from date of accident
15. Unreasonable or unnecessary expenses 17. Other, explained below
HEALTH SERVICE BENEFITS DENIED
18. Fees not in accordance with fee schedules 20. Treatment not related to accident
19. Excessive treatment, service or hospitalization
From
Through
21. Unnecessary treatment, service or hospitalization
From Through ___
22. Other, explained below:
COMPLETE ITEMS 23 THROUGH 30 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED
23. Provider of Health Service (Name, Address and Zip Code)
25. Date of bill
28. Amount of bill
$
26. Date received by insurer 29. Amount paid by insurer
$
24. Type of service rendered
27. Period of bill
30. Amount in dispute
$
31. State reason for denial, fully and explicitly (attach extra sheets if needed):
DATED
Name and Title of Representative of Insurer
TELEPHONE NUMBER: __________
EXT._____
NYS FORM NF-10 (Rev9/2001)
19
DENIAL OF CLAIM FORM - PAGE TWO
IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS:
1. You may file a written complaint with:
NEW YORK STATE INSURANCE DEPARTMENT
CONSUMER SERVICE BUREAU
25 BEAVER STREET
NEW YORK, NEW YORK 10004
Although the Insurance Department will attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed claim. If you wish to file a
complaint, send one copy of this Denial of Claim Form with copies of other pertinent documents with a letter fully explaining your complaint to the Insurance Department
at the above address. If you choose this option, you may at a later date still submit this dispute to arbitration or bring a lawsuit; or
2. You may submit this dispute to arbitration. If you wish to submit this claim to arbitration, mail a copy of this Denial of Claim Form with copies of other pertinent
documents together with a $40 filing fee, payable to the AMERICAN ARBITRATION ASSOCIATION (AAA) to:
NEW YORK NO-FAULT CONCILIATION CENTER
AMERICAN ARBITRATION ASSOCIATION
65 BROADWAY
NEW YORK, NEW YORK 10006
The filing fee will be returned to you if the arbitrator awards you any portion of your claim. You will not be required to pay the fees of the arbitrator, no matter how
the dispute is concluded. You may qualify for an expedited arbitration if the insurer has made a determination that your written justification for the late notice of claim
failed to meet a “reasonableness standard”. A request for expedited arbitration must be filed within 30 days of date of denial. A complete submission must be provided,
as there is no oral testimony in an expedited arbitration and no request for additional documentation, unless specifically requested by the arbitrator. The decision of an
arbitrator is binding, except for limited grounds for review set forth in the Law and Insurance Department Regulations; or
3. You may bring a lawsuit to recover the amount of benefits you claim to be entitled to.
IF YOU ARE CONTESTING THE DENIAL OF CLAIM AND WISH TO SUBMIT THE DISPUTE TO ARBITRATION, STATE ON ACCOMPANYING SHEETS THE
REASON(S) YOU BELIEVE THE DENIED OR OVERDUE BENEFITS SHOULD BE PAID. SUPPLY DETAILS, SIGN BELOW, AND SEND THE COMPLETED FORM
TO THE INSURANCE DEPARTMENT AT THE ADDRESS GIVEN IN ITEM 2 ABOVE.
Loss of Earnings: Date claim made: Gross Earnings per month $
Period of dispute: From Through Amount Claimed: $
Health Services: (Attach bills in dispute.)
Name of Provider
Date of Service Amount of Bill Amount in Dispute Date Claim Mailed
Other Necessary Expenses: (Attach bills in dispute.)
Type of Expense Claimed
Amount Claimed Date Incurred Date Claim Mailed Amount in Dispute
Other: (Attach additional sheets, if necessary.)
Telephone number of applicant or applicant's representative during regular business hours:
Mail a copy of this form to the insurer against whom you are requesting arbitration and retain a copy for your records.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF
CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Date Signature
Applicant or Representative
ARE YOU AN ATTORNEY?
YES NO
NAME OF FIRM
FIRM ADDRESS
IMPORTANT NOTICE TO APPLICANT
If box number 3 ("Policy not in force on date of accident") on the front of this form is checked as a reason for this denial, you
may be entitled to No-Fault benefits from the Motor Vehicle Accident Indemnification Corporation
(M.V.A.I.C.)(212-791-1280) located at 110 William Street, New York, New York 10038. The Insurance Law requires that you
must file an Affidavit of Intention to Make Claim with M.V.A.I.C. Therefore, it is in your best interest to contact the M.V.A.I.C.
immediately and file such an affidavit, even if you intend to contest this denial.
NYS FORM NF-10 (Rev9/2001)
20
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ADDITIONAL PIP SUBROGATION AGREEMENT
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
*
NAME, ADDRESS AND PHONE NUMBER
OF INSURER’S CLAIMS REPRESENTATIVE
*
DATE
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT
*
Dear Applicant:
Kindly complete and return this agreement at once. Failure to do so may delay payment of your No-Fault Benefits.
SUBROGATION AGREEMENT
TO _________________________________
Company
(NAME OF INSURER)
The undersigned hereby declares that a bodily injury was sustained by:
ON 19
(NAME OF APPLICANT) (DATE OF ACCIDENT)
and a claim for extended economic loss benefits (medical, loss of earnings, other reasonable and necessary expenses and/or a death benefit) is
being made under policy number __________
issued to
In consideration for benefits paid or payable under the additional personal injury protection endorsement of the foregoing policy, it is agreed that:
1. In accordance with the provisions of the policy, the company is subrogated to the extent of any payment for additional first-party
benefits to the rights of the applicant against any person because of bodily injury with respect to which additional personal injury protection
benefits are afforded under this policy.
2. The undersigned shall cooperate with the company and upon the company's request, assist in the conduct of suits and in enforcing
any company right of subrogation for additional personal injury protection benefits paid against any person who may be liable to the injured
person because of bodily injury with respect to which additional personal injury protection benefits are afforded under this policy.
3. The undersigned to or for whom payments are made or the undersigned's legal representative will notify the company in writing prior to
institution of any legal proceedings against any person legally responsible for the above described bodily injury and will do whatever is necessary
to secure and to do nothing to prejudice the company's subrogation rights.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
I have read the foregoing subrogation agreement, understand its contents and have signed the same as my free act.
__________ DATE
SIGNATURE OF APPLICANT
BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER
NYS FORM NF-11 (Rev9/2001
)
21
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
LUMP-SUM SETTLEMENT AGREEMENT
NAME AND ADDRESS OF INSURER
OR SELF-INSURER
*
DATE
NAME OF POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
_________________ OF ___________
NAME OF APPLICANT FOR BENEFITS ADDRESS OF APPLICANT
has applied to ______________________________
Name and address of Insurer or self-insurer
for benefits for loss of earnings from work sustained as a result of injury arising out of the use or operation of a motor vehicle.
Dr. __________
OF ______________________
NAME ADDRESS
has examined the applicant and has certified in a report executed on
, a copy of which is annexed to this
Agreement, that in his medical judgment the applicant's injury will result in a period of disability which will extend for at least 3 years beyond the
date of the accident causing the injury. Such report further certifies that a lump-sum settlement of the applicant's loss of earnings from work will
be of material benefit to the applicant occupationally and from a rehabilitative standpoint.
The sole obligation of __________________
for the applicant's loss of earnings
NAME OF INSURER OR SELF-INSURER
from work, for a projected period of disability from the date of this agreement of __
years, months,
shall be the payment of $
, which is the present value of such loss of earnings from work which would otherwise have been payable
during this period computed on the basis of a 6 percent annual interest factor and any other applicable offsets, and subject to the provisions of
Article 51 of the New York Insurance Law and any applicable policy endorsements. A worksheet setting forth the assumptions and
computations utilized in deriving the lump-sum settlement value is attached.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT
OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS
AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
_________________
____________________
DATE SIGNATURE OF APPLICANT OR APPLICANT'S
AUTHORIZED REPRESENTATIVE
_________________ ____________________
DATE SIGNATURE OF REPRESENTATIVE OF
INSURER
The agreement executed above must be approved either by a court of competent jurisdiction or by an arbitrator. If an arbitrator's approval is
requested, the arbitrator must complete the following for the Lump-Sum Settlement Agreement to be valid:
I, ______________________________
, as Arbitrator appointed pursuant to the provisions of the
NAME OF ARBITRATOR
New York Comprehensive Motor Vehicle Insurance Reparations Act, having reviewed the foregoing application and supporting documents, do
hereby approve the lump-sum settlement agreed to herein and do direct that it shall be paid.
__________
______________________
DATE SIGNATURE OF ARBITRATOR
*BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OF SELF-INSURER, AS APPROPRIATE
NYS FORM NF-12
(Rev9/2001)
22
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ELECTION OF OPTION - OPTIONAL BASIC ECONOMIC LOSS COVERAGE
NAME AND ADDRESS
OF INSURER OR SELF-INSURER
DATE OF MAILING
POLICYHOLDER
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF CLAIMANT
Dear No-Fault Claimant:
The injury you sustained in the captioned accident is covered under a policy which includes an additional $25,000 of basic economic loss
coverage ("Optional Basic Economic Loss" or "OBEL" coverage). Our records indicate that the expenses incurred because of your injuries may
come within this additional $25,000 of basic economic loss coverage. The No-Fault law gives you the opportunity to elect how your want the
additional $25,000 of coverage to be spent.
In order that we may continue to process your claim, please make your designation by placing a check mark in one of the boxes below,
next to the option your wish to elect.
(1) basic economic loss which includes health service expenses, loss of earnings from work, and other reasonable and
necessary expenses; or
(2) loss of earnings from work, less statutory offsets; or
(3) psychiatric, physical or occupational therapy and rehabilitation; or
(4) a combination of options (2) and (3).
Please return this completed form to the insurer or self-insurer at the address given above within 15 calendar days from the date of this
letter. You are advised that if you fail to complete and return this form within the time specified, it will be assumed that you have elected to apply
OBEL coverage to option (1) above. You are further advised that, once an election is made, it cannot be changed.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Dated:
. _______________________________
SIGNATURE OF CLAIMANT OR LEGAL REPRESENTATIVE
_______________________________
(PRINT NAME OF LEGAL REPRESENTATIVE, IF APPLICABLE)
NYS FORM NF-13
(Rev9/2001)
23
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ARBITRATION REQUEST FORM
(FOR PERSONAL INJURIES SUSTAINED ON AND AFTER 12/1/77)
OPTIONAL NO-FAULT ARBITRATION IS FINAL AND BINDING EXCEPT FOR THE LIMITED
GROUNDS FOR REVIEW SET FORTH IN THE LAW AND REGULATIONS. UPON RECEIPT OF
THIS REQUEST, THE AMERICAN ARBITRATION ASSOCIATION (AAA) WILL ATTEMPT TO
RESOLVE THE DISPUTE. IF THE DISPUTE CANNOT BE RESOLVED, YOUR CASE WILL BE
FORWARDED TO THE APPROPRIATE ARBITRATION FORUM. IF YOU WISH TO ARBITRATE
YOUR CLAIM COMPLETE BOTH SIDES OF THIS FORM TO THE BEST OF YOUR ABILITY.
PLEASE PRINT OR TYPE.
APPLICANT FOR BENEFITS
LAST NAME FIRST NAME ADDRESS
AS ASSIGNEE
ÿ YES
ÿ NO
INJURED PERSON
LAST NAME FIRST NAME ADDRESS
DATE OF ACCIDENT
POLICYHOLDER
LAST NAME FIRST NAME ADDRESS
POLICY NUMBER
INSURER OR SELF-INSURER
INSURER’S CLAIMS OFFICE ADDRESS
INSURER’S REPRESENTATIVE
TELEPHONE NUMBER CLAIM OR FILE NUMBER
ACCIDENT LOCATION
___________________________________________________________________________________________________________________________
DESCRIPTION OF ACCIDENT
___________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
WAS INSURER CONTACTED AFTER CLAIM WAS SUBMITTED ________________________________________________________________________
_________________________________________________________________________________________________________________________
NAME AND TITLE OF PERSON CONTACTED? __________________________________________________________________________________
_________________________________________
DATE OF LAST CONTACT? ___________________________________________________________________________________________________
REASON GIVEN BY INSURER FOR NONPAYMENT OF CLAIM(S) DETAILED ON REVERSE SIDE: _____________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
REASON YOU BELIEVE THE DENIED OR OVERDUE BENEFITS SHOULD BE PAID ___________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
SUPPLY DETAILS OF DISPUTE ON REVERSE SIDE
FORM AR (9/2001)
24
DETAILS OF DISPUTED CLAIM
Loss of Earnings: Date claim made:_______________ Gross earnings per month:$ _________________
Period in dispute: From: _______________ To: _____________ Amount claimed: _________________________
Medical (Attach bills in dispute):
DOCTOR, HOSPITAL OR
OTHER HEALTH PROVIDER
AMOUNT
OF EACH
BILL
AMOUNT
PAID
UNPAID OR
DISPUTED
BALANCE
DATES OF SERVICE DATE BILL
MAILED
WAS VERIFICATION REQUESTED
NO YES DATE
SUPPLIED
Other Necessary Expense(s) (Attach bills in dispute):
TYPE OF EXPENSE CLAIMED AMOUNT CLAIMED DATE INCURRED DATE MAILED AMOUNT IN DISPUTE
Death Benefit: Date Death Certificate Mailed To Insurer:_____________________________
Interest
BENEFIT PAID LATE AMOUNT OF BILL DATE MAILED TO
INSURER
WAS VERIFICATION REQUESTED?
NO YES SUPPLIED DATE
DATE PAID BY INSURER
Attorney’s Fee
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
THIS FORM IS SUBSCRIBED AND AFFIRMED
BY THE APPLICANT AS TRUE UNDER THE PENALTY OF PERJURY
THE APPLICANT AFFIRMS THAT A COPY OF THIS COMPLETED FORM HAS BEEN MAILED
TO THE INSURER AGAINST WHOM ARBITRATION IS BEING REQUESTED
ARBITRATION REQUESTED BY:
LAST NAME FIRST NAME
NAME OF LAW FIRM, IF ANY
TELEPHONE NUMBER
ADDRESS
SIGNATURE
ARE YOU AN ATTORNEY?
ÿ YES ÿ NO
DATE
HOW TO FILE
1. MAIL THIS COMPLETED FORM AND ALL REQUESTED ATTACHMENTS IN DUPLICATE TOGETHER WITH A $40.00 FILING FEE PAYABLE TO THE AMERICAN ARBITRATION
ASSOCIATION TO:
NEW YORK NO-FAULT CONCILIATION CENTER
AMERICAN ARBITRATION ASSOCIATION
65 BROADWAY
NEW YORK, NEW YORK 10006
2. MAIL A COPY OF THIS FORM TO THE INSURER AGAINST WHOM YOU ARE REQUESTING ARBITRATION AND RETAIN A COPY FOR YOUR RECORDS.
FORM AR (9/2001)
