No-Fault Denial – Why Didn’t No-Fault Pay My Medical Bill?

Why did I receive a “New York Motor Vehicle No-Fault Insurance Law Denial of Claim Form” indicating that the No-Fault insurance company did not pay my doctor’s bill?

Because your No-Fault insurance company either paid for a benefit or denied a benefit — keep reading.

If you were in a car accident or a pedestrian hit by a car, you will receive a New York Motor Vehicle No-Fault Insurance Law Denial of Claim Form if you went to a hospital or saw a doctor.

We get calls all the time from people asking why the No-Fault insurance company didn’t pay the doctor’s bill and whether they are responsible for it.

Assuming that 1) you filed the application for No-Fault benefits on time, 2) your doctor sent the bill to your No-Fault insurance company within 45 days, and 3) your No-Fault benefits are still available, the Denial of Claim form is probably indicating that the doctor’s bill was paid.

Why No-Fault Denial of Claim Forms Are Confusing

What confuses everyone is that every time a medical provider gets paid by No-Fault, the insurance company sends you a No-Fault Denial of Claim Form, even if the insurance company pays 100% of the bill.

When you receive a No-Fault Denial of Claim Form, you should read the reason for the denial, which is usually at the bottom of the first page, with a further explanation on the second or third page.

Most Common Reasons for No-Fault Denials

The No-Fault Denial of Claim Form explanation at the bottom of the page will tell you if:

• The doctor billed more than the allowable amount (you are not responsible for this amount if you signed an assignment) – See below.
• You had a $200 per accident deductible, which is being applied, or
• You received medical treatment after you were denied further medical treatment.
• Any other reason your No-Fault claim may have been denied.

Do I Have to Pay a Co-Payment Every Time I See a Doctor?

No. There are no co-payments for medical treatment paid by No-Fault when you are injured in a car accident.

Why Is No-Fault Refusing to Pay My Medical Bill?

To understand why the insurance company is denying your claim, you must carefully read at the bottom of the No-Fault denial form where it says, “State reason for denial, fully and explicitly.”

No-Fault Deductible

Many people have a $200 deductible, and this should be the only amount you are responsible for paying.

No-Fault Paid Less Than What the Doctor Billed

Most of the time, No-Fault insurance will not pay the entire medical bill, and the difference is indicated in box #32, Amount in Dispute.

This is usually because the medical provider billed more than the allowed amount. Your doctor may send a bill for $300, but the No-Fault insurance company might only pay $78. The No-Fault insurance company is only required to pay the rate indicated on the Worker’s Compensation fee schedule.

Don’t worry! If your doctor billed the insurance company (not you), then the doctor accepted an assignment of your claim, and you are not responsible for paying the difference.

You Were Denied Further Medical Treatment

Several months after your car accident, the No-Fault insurance company will have you examined by their doctor, who may deny further medical treatment.

Your No-Fault insurance company will have you examined by each medical specialty for which you have been treated.

For instance, if you have been treated by a chiropractor, orthopedic surgeon, and neurologist, you will be scheduled for three No-Fault medical exams.

If you are denied further treatment by a neurologist examining you for the no-fault insurance company, you can still see an orthopedic surgeon because they are in different medical specialties.

After going to a No-Fault physical examination, you will also receive a denial of claim form, which may either deny all further medical treatment and benefits, deny further treatment from a particular medical specialty, or allow further medical treatment until a certain date. Again, you must carefully read the reason stated at the bottom of the form.

If, after a No-Fault exam, you have been denied further treatment and continue receiving treatment for the denied medical specialty, you will become responsible for the medical bills.

When No-Fault denies further treatment, your medical bills can be submitted to your health insurance or Medicare.

If you have been denied further medical treatment and you do not have health insurance or Medicare, we can still obtain medical treatment for you without any upfront cost to you.

Can I Pay My Doctor and Get Reimbursed by No-Fault?

This is a bad idea that will cost you a lot of money.

If you paid the doctor at the time of treatment and submitted the bill to No-Fault yourself, you’ll be on the hook for the amount of the difference between what the doctor billed you and the amount that No-Fault will pay.

The difference can cost you a lot of money. But there is no reason for you to ever pay a doctor directly. When the doctor bills No-Fault directly, the doctor cannot charge you for the difference.

How to Make Sure You Won’t Have to Pay Your Doctor for Medical Treatment When Injured in a Car Accident

1. Ask the doctor if he or she accepts No-Fault.
2. If the doctor does accept no-fault, you will be asked to sign a form that says “Assignment of Benefits.” YOU SHOULD SIGN THIS FORM. This form allows the doctor to get a directly from no-fault, and you are no longer responsible for the medical bill as long as your no-fault coverage is still valid and you have not been denied further treatment. If you sign an assignment form, you are not responsible for the portion that was denied.

Can I Go to Any Doctor I Want if I Have No-Fault Insurance?

Yes. You can go to any doctor or medical facility that accepts No-Fault insurance. Almost all doctors and medical facilities accept No-Fault. If you go to a doctor who accepts No-Fault insurance and you sign an assignment, you will not be responsible for paying the difference between what the doctor bills you and the amount that No-Fault will pay.

You can even go to any doctor or medical facility that does not accept No-Fault, but you will be charged upfront, and you will be responsible for paying the difference between what the doctor billed you and the amount that No-Fault will pay.

Do All Doctors Accept No-Fault as Payment for Medical Treatment?

No. Almost all doctors accept no-fault as payment for medical treatment. But there are some orthopedic surgeons and other doctors who do not accept No-Fault.

Plastic surgeons and dentists typically do not accept No-Fault. But if you need treatment by a plastic surgeon or dentist because of a car accident, we can almost always get your plastic surgeon or dentist to agree to accept No-Fault insurance.

Will No-Fault Pay a Plastic Surgeon for Plastic Surgery?

Yes, and you do not have to pay in advance! But plastic surgery is handled very differently with No-Fault than other injuries, and you need to call us before you get treatment.

Your plastic surgeon will tell you that you must pay in advance and get reimbursed by your no-fault insurance. If you do that, not only will you have to advance the money to your plastic surgeon, but you will be reimbursed a lot less than you paid.

Will No-Fault Pay a Dentist for Dental Treatment?

Yes. However, payment from no-fault for treatment of dental injuries is handled very differently than other injuries, and you need to call us before you get treatment. Your dentist will tell you that you must pay in advance and get reimbursed by your no-fault insurance. If you do that, not only will you have to advance the money to your dentist, but you will be reimbursed a lot less than you paid.

If you need medical treatment from a plastic surgeon or dentist, you should call us immediately. We know how to get your plastic surgeon or dentist to accept No-Fault, so you don’t have to pay any money out of pocket. Most other personal injury lawyers do not know how to do that. We know because people call us frequently when their personal injury lawyer doesn’t know how to get them medical treatment from a plastic surgeon or dentist.

If you were in a car accident or a pedestrian hit by a car, please call us for a free consultation.

Did the Insurance Company or Your Doctor Say Your No-Fault File Was Closed?

If you were told that your no-fault file was closed, you need to read why your no-fault file is probably not closed and how to reopen your No-Fault file.

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