Understanding No-Fault Law

As a courtesy, we’ve listed some of the more commonly asked questions health care professionals might have regarding No-Fault Law, referenced from the New York State Insurance Department. If you have questions regarding No-Fault Law, we encourage you to contact us and schedule a no-obligation consultation.

What are some of the more significant regulatory changes in automobile No-Fault insurance that have occurred as a result of the Department’s promulgation of the revised Regulation 68?

Insurance Department Regulation 68, as revised effective April 5, 2002, effected numerous changes to the processing of No-Fault claims. The revised Regulation modified the timeframes in which to submit written notice of claim from 90 to 30 days and to submit medical bills from 180 to 45 days, respectively, and mandated that lost wage claims must be submitted within 90 days. The new regulation also included provisions for the electronic data transmittal of claim information, and revised rules concerning the wording and acceptance of No-Fault assignments. In addition, the revised regulation modified many of the administrative procedures in connection with No-Fault arbitration and conciliation.

Additional helpful links concerning Insurance Department Regulation 68, including the text of the old (pre-April 5, 2002) Regulation 68 as well as the version of Regulation 68 currently in effect along with all amendments promulgated to date, can be located here.

When do the provisions establishing time frames of 30 days for written Notice of Claim, 45 days for submission of health care bills and 90 days for submission of loss of earnings claims take effect?

Insurers are required after April 5, 2002, to issue new prescribed endorsements for all new and renewal policies which contain the new requirements. These requirements can be applied only to claims that arise under policies issued which include the new endorsement.

I accepted a No-Fault assignment from a patient and rendered treatment. When I submitted the bill to the No-Fault insurer, they issued a denial of claim based on the results of an insurer medical examination (IME). Can I pursue the patient directly for payment of this bill?

No. A physician who has accepted a No-Fault assignment of benefits from a No-Fault patient may not pursue the patient directly for payment if the No-Fault carrier denies payment for services based upon a determination that the services were not medically necessary. Such action by the provider would not be permitted under the No-Fault assignment of benefits language contained in claim forms required by N.Y. Comp. Codes R. & Regs. tit. 11, § 65-3.11(b)(ii) & (iv) (2002) (Regulation 68-C).

The No-Fault assignment is considered a legal contract, wherein the health provider assignee assumes all of the legal rights and privileges of the injured party assignor. The assignee cannot arbitrarily disregard the provisions of a previously accepted No-Fault assignment. Inasmuch as a No-Fault assignment of benefits has been accepted and the No-Fault insurer denied continued treatments as not necessary or related to an automobile accident, the health provider is legally bound to resolve this question of fact through No-Fault arbitration or through a court of competent jurisdiction if they are in disagreement with the insurer’s denial of claim. A failure to exercise these remedies constitutes an acceptance of the insurer’s determination that health services rendered were not necessary, and under the terms of the assignment the health provider may not bill the patient for services rendered.

Source: NYS Insurance Department