- 1 What is No-Fault?
- 2 Can I Use My Health Insurance or Medicare To Pay My Medical Bills?
- 3 Who is covered by no-fault?
- 4 What does no-fault pay for?
- 5 How and when do I have to file a no-fault application?
- 6 Should I sign a legal document my doctor wants me to sign called an assignment?
- 7 Do I have to pay for any part of the hospital or doctors’ bills?
- 8 How much No-Fault insurance coverage do I have?
- 9 Do I have to go to the No-Fault insurance doctor for an examination?
- 10 Denial of No-Fault Benefits
- 11 Can my no-fault denial be opened up or reversed?
- 12 What is medical payments coverage?
What is No-Fault?
No-Fault is frequently misunderstood. It has nothing to do with who was at fault for an accident. No-Fault is not liability coverage. Think of No-Fault as health insurance and disability insurance when you’re in a car accident. No-fault is available only for people injured in car accidents and pedestrians.
No-Fault is also called Personal Injury Protection or “PIP”.
No-Fault gets its name from the fact that no-fault coverage is available to an insured regardless of who’s at fault. Before no-fault was enacted, auto insurers would fight over which insurance company would pay for medical bills and lost wages. The no-fault law eliminates costly legal fighting between insurance companies. A driver who caused a car accident will still get no-fault coverage from his/her own insurance company.
No-fault Is paid by the insurance company for the car you’re sitting in at the time of the accident or by the car which struck you if you are a pedestrian or bicyclist. No-fault is Article 51 of the New York Insurance Law which requires no-fault insurance coverage for car accidents.
Can I Use My Health Insurance or Medicare To Pay My Medical Bills?
NO, not initially. NYS law says that No-Fault is primary and health insurance or Medicare is secondary. This means that No-Fault MUST be the first insurance to pay your medical bills.
Because No-Fault is primary insurance coverage, that means medical bills for treatment of injuries from a car accident will not be paid by health insurance or Medicare until No-Fault has denied you further medical treatment.
If you request your doctors to bill your health insurance for Medicare instead of No-Fault, they will likely not agree but if they do, your health insurance company or Medicare could seek reimbursement from you when they find out you were injured in a car accident. It will also make it more difficult to settle your case.
If you do not file a no-fault application within 30 days of your accident you will lose important no-fault benefits such as payment for lost wages and household help.
Q. How will my health insurance or Medicare find out that I was injured in a car accident?
A. They have computer software which looks at the medical ICD codes to look for codes that have to do with medical treatment for trauma. When they see these codes, they began to investigate to determine if there was a car accident or some other accident where a lawsuit might be involved.
When Can You Submit Medical Bills to Your Health Insurance Company or Medicare?
You can submit medical bills to your health insurance company or Medicare only after No-Fault will no longer provide you coverage because further medical treatment was denied or No-Fault has paid out the maximum coverage you have.
Who is covered by no-fault?
No-Fault is available to anyone injured in a car accident, bicycle accident or pedestrian accident if you were not working in the course of your employment when the accident occurred. If you were working for your employer at the time of your accident, your bills will be paid by worker’s compensation and you should advise us immediately.
The car does not have to be moving! No-Fault will even pay you benefits if you were getting into a car or getting out of a car. We obtained No-Fault benefits for a client who was hit in the nose by the car door when she was getting out of a parked car.
The no-fault law does not provide coverage for occupants of a motorcycle in a motorcycle accident. However, a pedestrian struck by a motorcycle is entitled to no-fault benefits.
The No-Fault insurance company is usually the company insuring the car in which you were sitting at the time of the accident or the car that struck you if you were a pedestrian.
Use or occupation of a car includes pedestrian accidents and injuries caused by entering or getting out of a parked car. Pedestrians get No-Fault insurance from the car that hit them.
What does no-fault pay for?
No-fault insurance pays for various benefits including:
- Medical treatment including the ambulance; hospital; doctors; therapists; dentists; radiology and other diagnostics
- Medical appliances
- Household help
- Transportation to doctors (taxi, bus or mileage)
- Lost wages or lost income (80% of your lost gross wages is paid by No-Fault less lost wages paid by New York State Disability. A NYS Disability form must be given to your employer within 30 days of your accident)
- Funeral expenses (see more information about wrongful death)
How and when do I have to file a no-fault application?
A claim for no-fault insurance benefits must be filed within 30 days of the date of the car accident.
The no-fault insurance company is most often the car in which the injured person was sitting or the car which struck a pedestrian or bicyclist. However, determining the proper no-fault insurance company can be complicated and can take time. Therefore, it’s important to call a lawyer as soon as possible after a car accident to make sure that an application for no-fault benefits is filed with the correct insurance company within the 30-day time limit.
We will file a No-Fault claim and your No-Fault application for you.
If you were injured in a car accident; hit by a car while on a bicycle; hit by a car while a pedestrian; or just injured by a car whether it was moving or not, call us immediately. Even if you do not want to retain us at the time, we will be happy to tell you what to do. Call us seven days/nights at 1-800-487-8911.
How to fill out a NY No-Fault application yourself without a lawyer
- We do not enter your phone number on the No-Fault application because we don’t want them talking to you or getting a statement.
- For your injuries, list every part of your body because you only have 12 months to notify no-fault of an injury and sometimes injuries appear much later. We enter MULTIPLE PERSONAL INJURIES INCLUDING, BUT NOT LIMITED TO HEAD, BRAIN, JAW, NECK, BACK, LIMBS, JOINTS, TENDONS, LIGAMENTS, BODY, PSYCHOLOGICAL.
- For the accident description, write only “two-car collision”.
- You can answer all the other questions on the No-Fault application.
Should I sign a legal document my doctor wants me to sign called an assignment?
YES! The hospital and doctors you visit will usually request that you sign a paper which may be called “Assignment”. It allows the hospital or doctor to be paid directly by your no-fault insurance company. You should sign this paper (see why in the next paragraph).
Do I have to pay for any part of the hospital or doctors’ bills?
The advantage of signing an assignment is that the medical provider will not be allowed to bill you for any charges other than what they are paid by no-fault. If the hospital or doctor’s bill is $1,800 but is paid only $487 from no-fault, you are not responsible for the balance of $1,313.
IMPORTANT — If you visit a doctor who does not ask you to sign an assignment or is not willing to let you assign the claim to the doctor, you will be responsible for the difference between what no-fault pays you and what the doctor charges you. When a doctor does not have you sign an assignment, they will usually tell you that they will give you a bill which you can submit to no-fault. This will cost you!
Time to Submit Medical Bills
Bills for medical expenses must be submitted to the No-Fault insurance company within 45 days of incurring the expense. We can fax the no-fault information to your doctor or medical provider. If the doctor sends the medical bill in after 45 days, you will not be responsible for the bill.
TIP — People injured in a car accident often get stuck paying the ambulance bill because the ambulance often sends the bill directly to you and usually a lot more than 45 days after your accident. By that time it’s too late. You should make sure that the ambulance bill is sent to the no-fault insurance company within 45 days. The ambulance bill can cost as much as $500-$2,000. We can notify the ambulance company of your no-fault information and let them know that it if it is not submitted within 45 days, you will not be responsible.
See our page about lost wages and how much you are entitled to receive.
Receipts for household help should be signed and indicate the name and address of the person providing the service together with a copy of a picture ID from the provider.
Taxi & Transportation to Doctors
Receipts for transportation to doctors and No-fault exams should show the name of the company; date; the address from which you were picked up; and the address at which you were dropped off.
Other Necessary Expenses
The time period for submitting other necessary expenses is no more than 90 days after the necessary expenses were incurred. Receipts for expenses must show the amount you spent and the name of the company or person you paid.
Most people purchase no-fault insurance policies with a $100 deductible per accident. You are responsible to pay the deductible.
How much No-Fault insurance coverage do I have?
The minimum no-fault coverage required by New York State is $50,000 and is referred to as basic no-fault coverage. However, you can purchase additional no-fault coverage referred to as OBEL (Optional Basic Economic Loss).
The amount of coverage will be shown on the declarations page of your insurance policy. The declarations page is the page which shows all of your coverages and how much you are being charged. No-Fault will usually be shown as Personal Injury Protection or “PIP”.
Do I have to go to the No-Fault insurance doctor for an examination?
After a no-fault application is filed, you will be required to be examined by the no-fault insurance company’s doctors. The insurance companies refer to this exam as an IME or Independent Medical Exam. We refer to them as a no-fault exam because they really are not independent since the insurance company is paying the doctor to do the exam.
Most often, the no-fault insurance doctor will deny you further treatment. The IME doctor will usually deny further treatment by stating either that you have recovered from your injuries or that since you have not recovered after having received treatment for several months, further treatment will not help you.
If the no-fault insurance doctor allows you to have further treatment, you will be scheduled for another no-fault exam every 30 days until you have been denied further treatment.
The no-fault insurance doctor can only deny you benefits in his/her field. For instance, a neurologist can only deny you treatment by a neurologist and cannot deny you treatment by an orthopedic surgeon.
Your first no-fault exams will usually take place within 3-6 months after your accident.
Your examination is required to be held in the county in which you live. If you need to take a taxi, you must obtain a properly filled out receipt to be reimbursed. You can also be reimbursed if you have to take the day off from work.
You are allowed to change the date of the examination only once. If you miss a rescheduled no-fault examination, you will be denied all medical benefits.
There are several reasons why it is very important for you to go to the no-fault insurance physical, even if you will be denied further treatment. The most important is that your failure to appear at the examination can result in a denial of all your benefits. Additionally, while usually overlooked by many lawyers, we are usually able to use the no-fault examination report to help your case.
If you have been denied further treatment by the no-fault insurance doctor, you can now start submitting your medical bills to your health insurance company or Medicare. If you do not have any medical insurance, we can arrange your doctor to get paid at the end of your case.
After your No-Fault benefits have been denied, you should continue to send your medical bills to No-Fault, even though No-Fault will not pay them and even though major medical insurance or Medicare is paying the bills or the doctor has accepted a lien! The reason for submitting these bills to No-Fault is that No-Fault will not consider a bill which has been sent to them more than 45 days after the date of treatment. If you continue to timely send the bills to No-Fault, it may then be possible to sue the No-Fault insurance company at a later date.
No-fault medical examinations should not be confused with defense insurance medical examinations when you have a lawsuit.
Denial of No-Fault Benefits
The Explanation of Benefits from no-fault is called a denial which is why you continue receiving denials.
Every time a doctor gets paid, you will receive a denial of no-fault benefits showing how much the doctor was paid and what portion of the bill was denied. You are not responsible for the difference. See what you are and are not responsible to pay when you see a no-fault doctor.
If you are denied further medical treatment after you have been examined by the No-Fault doctor, you MUST NOT use the form to file an arbitration to fight the denial. If you fight the No-Fault denial either by arbitration or in court, YOU COULD KILL YOUR LAWSUIT.
If you have health insurance, simply use your health insurance. If you do not have health insurance, we may be able to get your No-Fault denial reversed and we can arrange for you to receive further medical treatment where the medical facility gets paid from your case.
Can my no-fault denial be opened up or reversed?
Insurance companies frequently say they closed your no-fault file when it was not closed and your no-fault file can easily be reopened. However, a no-fault claim can rarely be closed.
Your no-fault claim can be closed if it runs out of money because all of it was paid for your medical treatment or if you violated policy terms such as failing to appear for a physical exam.
If you were denied further no-fault benefits because of a no-fault physical, your claim has not been closed and it is possible to re-open it. We have done that many times. However, it is time-consuming and we have only done that when our client could not get surgery because benefits were denied.
Your accident lawyer should not arbitrate a no-fault denial or file a lawsuit against the no-fault insurance company to reopen your no-fault claim until after your personal injury case is finished. Otherwise, it could jeopardize your personal injury case. We have successfully reversed no-fault denials without arbitration or a lawsuit, where our client needed surgery.
What is medical payments coverage?
Medical payments coverage or “Med Pay” Is additional insurance coverage for medical payments. This is completely separate from and has nothing to do with no-fault. It is usually sold in small increments of $1,000 to as much as $20,000.
Medical payments coverage should be used by you to submit bills that are not covered by no-fault such as over the counter medication, No-fault deductible, and copayments and deductibles from your health insurance after no-fault has been denied.
At HURT911® you can speak with Dream Team Partners Rob Plevy, Esq. and Phil Franckel, Esq. whenever you need, days/nights/weekends.