When someone refers to “no-fault,” in the context of automobile accidents, they are referring to insurance coverage for medical bills, lost wages, and other necessary expenses incurred as a result of a motor vehicle accident. These elements encompass “basic economic loss,” and are often the most important concerns for someone injured in a motor vehicle accident. No-Fault, also referred to as Personal Injury Protection (PIP), is designed to pay promptly, regardless of who is at fault or whether there was any negligence on the part of the claimant.
Every car insurance policy issued in New York must, by law, include no-fault coverage. The New York State required minimum amount of no-fault insurance coverage found in every auto policy is $50,000.00 per person, per accident. Additional protection can be purchased from an insurance carrier, but every policy must have the $50,000.00 coverage minimum. This coverage will also extend to any pedestrian injured by the insured vehicle.
A claim by an eligible injured person, or “EIP,” is a direct claim made by a party injured in an auto accident. The injured party makes the claim against the first party benefits insurance carrier, also known as the “no-fault insurance carrier.” It is a first party benefit stemming from the contract between the insurer and the insured.
What EIP benefits are recoverable under the NYS No-Fault Statute?
- Medical Benefits – All necessary medical expenses relating to medical treatment incurred as a result of the accident.
- Lost Earnings – 80% of wages lost due to the motor vehicle accident, up to $2000.00 a month for up to 3 years from the date of accident, unless more lost wage coverage was purchased or additional types of coverage were purchased. (1)
- Reasonable and Necessary Expenses – Up to $25.00 a day, for up to one year from the date of accident.
- Death Benefit – A $2,000.00 death benefit (over the $50,000.00 basic no-fault limit), payable to the estate of a person eligible for no-fault benefits who is killed in a motor vehicle accident.
What EIP claims are recoverable if denied by the no-fault insurance carrier?
A carrier for a variety of reasons may deny the above claims for first party benefits. The aggrieved party may dispute any claim denied by a carrier that is encompassed above. The following is a list of the most common no-fault insurance claims we pursue for EIP clients:
- Medical Benefits – EIP claims for medical expenses most often arise from statutory or contractual liens against a personal injury case.
- Medical Provider Lien – In most circumstances an EIP will assign their benefits to a medical provider, and the provider will pursue payment directly from the no-fault carrier after the denial of claims is issued. There are times, however, when the provider will take a contractual lien against the EIP’s personal injury file instead. When these liens are paid with proceeds from a personal injury settlement, the injured personal injury client may be entitled to reimbursement from their no-fault carrier if the medical services should have been covered under no-fault and were wrongly denied.
Our firm recently recovered a medical lien payment for an EIP where the personal injury law firm paid a healthcare provider pursuant to a contractual lien against the client’s personal injury settlement. In this case, the medical provider and patient rescinded the assignment of benefits after the Independent Medical Exam (IME) cutoff denial by the no-fault carrier.
We advised the client to continue treatment where the treating doctor found and advised that it was medically necessary. The treating doctor, and the client, agreed to payment for the treatment by placing a lien against the client’s personal injury case to cover the costs of further treatment.
When the personal injury case settled, the $7,000.00 medical lien was paid out of the client’s personal injury settlement proceeds to the medical provider. Our firm pursued recovery against the no-fault insurance carrier on the grounds that the IME wrongly denied benefits as the treating doctor’s objective and subjective findings, along with contemporary medicals, warranted further treatment, and established medical necessity of those treatments.
Prior to a hearing, a settlement was negotiated whereby the client received nearly the full $7,000.00 in reimbursement for lien payments made from his personal injury settlement, as the no-fault carrier should have paid the medical bills in the first place.
- Medicare, Medicaid, and Major Medical Insurance Liens – When Medicare, Medicaid, or other statutory lienholders pay for services that otherwise should have been covered by no-fault insurance, a statutory lien is imposed against a client’s personal injury settlement.
After the lien has been negotiated and paid, reimbursement can be pursued against the no-fault carrier, if the no-fault carrier should have paid the services originally, but did not. Our firm routinely handles statutory lien resolutions against no-fault carriers and obtains reimbursement pursuant to the no-fault fee schedule.
We recently had a client who received substantial rehabilitative treatment in a 24-hour facility after a spinal fusion related to her motor vehicle accident. As the procedure was done after the insurance carrier denied coverage pursuant to an “independent medical exam,” the treatment was billed to Medicare.
When the EIP’s personal injury case settled, Medicare enforced the lien against her settlement. We were able to recover the nearly $8,000.00 the client paid out from her settlement at a subsequent hearing.
- Lost Earnings – These are claims for lost wages due to an inability to work related to injuries resulting from a motor vehicle accident. The no-fault insurance carrier will often dispute that the EIP was disabled and will often claim that the EIP could have returned to work at an earlier date and deny said claims.
Our firm handled one such case recently where the EIP client was entirely at fault for the one car motor vehicle accident. Regardless of the EIP’s liability for causing the accident, his lost wage claims were covered under no-fault.
We pursued the claim against his auto insurance company for reimbursement for the time he missed from work due to the injuries he suffered in the accident. The insurance carrier denied his claim based on an IME, which stated he could return to work, because he was allegedly no longer disabled.
We brought the claim against the insurance carrier and won, recovering $14,000.00 of lost wages for the applicant.
The same client brought two other additional claims for lost wages for different time periods of lost employment. After winning the first claim against the carrier, all the subsequent claims settled. Overall, we recovered over $60,000.00 in lost wages for our client. (2)
- Reasonable and Necessary Expenses – Reasonable and necessary expenses of up to $25.00 a day may be recoverable where initially denied by the carriers. Some examples of reasonable and necessary expenses include travel to and from doctor appointments, household assistance or co-payments for treatment.
Recently with the help of the client, who kept records of her household expenses and mileage to and from the doctor after her motor vehicle accident, we filed the case for ADR to recover reasonable and necessary expenses and a settlement was quickly reached, and there was no need for the EIP to even appear and testify at a hearing.
These are just a small sample of common claims brought on behalf of EIPs against no-fault insurance carriers. At TonaLaw, we have been successfully resolving no-fault insurance claims for clients for over 24 years and we work with personal injury firms throughout New York to resolve EIP claims for their clients once the personal injury cases are closed. If you have any questions regarding the contents discussed herein, please feel free to contact us at 631-780- 5355 or email@example.com
(1) Additional coverages include OBEL (Optional Basic Economic Loss)/APIP (Additional Personal Injury Protection). This coverage is subject to offsets for New York State Disability Benefits, Workers Compensation and Federal Social Security Disability Benefits.
(2) This client had APIP coverage, which allowed recovery in excess of the $50,000.00 base policy.