No-Fault Insurance Claims
New York No-Fault Insurance Claims:
Protecting Your Right to Benefits
At No Fault Wizard, we specialize in helping medical providers—especially physicians and multidisciplinary clinics—navigate the complexities of New York’s no‑fault insurance system. When insurers deny, underpay, or delay reimbursement for treatments related to auto accidents, doctors need a knowledgeable legal and billing recovery team in their corner.
At No Fault Wizard, we are dedicated to ensuring that insurance companies honor their legal obligations. We represent both medical providers and individual policyholders throughout New York State, fighting for the compensation you deserve for essential medical care and other related expenses.
Understanding Your No-Fault Benefits
Under New York’s no-fault laws, your Personal Injury Protection (PIP) coverage is designed to cover specific “basic economic losses.” This coverage has a minimum limit of $50,000 per person and applies to a range of expenses, including:
Medical Expenses:
This includes costs for doctors’ visits, hospital stays, physical therapy, prescription drugs, and other necessary medical and rehabilitation expenses.
Lost Wages:
If your injuries prevent you from working, no-fault insurance will reimburse you for 80% of your lost earnings, up to a maximum of $2,000 per month, for up to three years. You may also be eligible for benefits from New York State Disability, which can be coordinated with your no-fault benefits.
Out-of-Pocket Expenses:
You are eligible for reimbursement for other reasonable and necessary expenses, such as transportation to and from medical appointments or hiring help for household chores, up to $25 per day for one year after the accident. A $2,000 death benefit is also available.
Why Your Claim May Be Denied and How We Fight Back
Insurance companies frequently employ tactics to deny or terminate no-fault benefits. We have extensive experience countering these strategies, which often include:
Independent Medical Examination (IME) Denials: These “examinations” are a misnomer. The medical examiners are hired by the insurance company and are often not truly independent. The exams are typically brief, and the resulting reports frequently conclude that further treatment is not medically necessary. We help rebut these biased reports with evidence from your personal treating physicians.
Peer Review Denials: In a peer review, an insurance company’s “expert” doctor reviews your medical records without ever examining you, and then recommends that your treatment be terminated. We work with your doctors to fight back against these record-based denials.
Biomechanical Reports: This is perhaps the most insidious denial mechanism. A “biomechanical expert” reviews accident reports and photos to argue that the force of the accident could not have caused your injuries. We challenge these reports, which are often used to terminate benefits even when your injuries are objectively documented.
Denials for Other Non-Payment Issues: We have successfully handled a wide range of non-payment issues, including denials related to small business ownership, contract workers, and coverage disputes.
Continuing Care is Crucial After a Denial
A denial from your insurance carrier does not mean you should stop receiving treatment. To the best of your ability, it is vital to continue to receive care and follow your personal treating physician’s recommendations. Large gaps in treatment are difficult to explain and can weaken your case. We work with a network of medical offices that will continue to treat patients even after a no-fault denial, helping you maintain continuity of care.
Our Provider Services
Navigating the New York no-fault system requires a deep understanding of the relevant statutes and regulations. We are well-versed in the laws that govern your benefits, including:
- N.Y. Ins. Law § 5102: This statute defines “basic economic loss” and outlines the specific benefits covered by your no-fault insurance, including medical expenses, lost wages, and other necessary expenses.
- 11 NYCRR 65: Known as “Regulation 68,” this is the New York State Department of Financial Services’ comprehensive regulation that governs the processing of no-fault claims. It sets strict timelines for insurers to acknowledge, investigate, and either pay or deny claims.
- No-Fault Application Deadlines: Under New York law, you must file a no-fault application (Form NF-2) with the insurer of the vehicle you were in (or the striking vehicle if you were a pedestrian) within 30 days of the accident. Medical providers must submit bills within 45 days of treatment. We ensure all documentation is filed correctly and on time to protect your rights.
Our approach is designed to streamline the claims process and maximize your chances of a successful outcome. Our process includes:
- Document Review and Filing: We will review all related documents, including your signed assignment of benefits, denied bills, denial letters, and all medical records. Our goal is to file the necessary paperwork within seven days of receiving all documentation.
- Challenging the Insurance Carrier: The burden is on the insurance company to prove that your medical treatment was not medically necessary. We meticulously build your case and are prepared to challenge any initial denials based on IMEs, peer reviews, or biomechanical reports.
- Rebuttal and Escalation: Even if the insurance company initially submits the proper evidence for a denial, we have an opportunity to rebut their submission with additional evidence. If a fair settlement cannot be reached, we are prepared to pursue arbitration or litigation to secure the benefits you are owed.
The outcome of a no-fault claim dispute can vary, but our goal is always to achieve a favorable result for our clients. We pursue several avenues to resolve disputes:
- Settlement: Many no-fault disputes are resolved through negotiation and settlement. We work to reach an agreement with the insurance carrier that provides full or partial payment of the outstanding benefits. Settlements are often a quick and efficient way to resolve claims without the need for a formal hearing.
- Arbitration: If a settlement cannot be reached, we will file for arbitration with the American Arbitration Association (AAA), as outlined in New York’s no-fault regulations. During this process, an independent arbitrator—typically an attorney with experience in insurance law—reviews the evidence from both sides and issues a binding decision. The award may include the full amount of the unpaid benefits, as well as interest and attorney’s fees.
- Litigation: For cases that require a more formal legal process, we are prepared to file a lawsuit in court. Litigation is often the best course of action for complex claims or when the insurance company refuses to engage in good-faith negotiations or arbitration. In a successful litigation case, a judge will issue a judgment that compels the insurance company to pay the benefits you are owed.