Current through Register Vol. 46, No. 39, September 25, 2024
(a)
Institution of claims for first-party benefits-priority.
(1) Subject to paragraph (9) of this subdivision, an applicant who
is an operator or occupant of an insured motor vehicle, or any other person,
not occupying another motor vehicle or a motorcycle, who sustains a personal
injury arising out of the use or operation in New York State of such motor
vehicle, shall institute the claim against the insurer of such motor
vehicle.
(2) An applicant who is
neither an operator nor an occupant of a motor vehicle or a motorcycle, and who
sustains a personal injury arising out of the use or operation in New York
State of more than one insured motor vehicle or insured motorcycle shall
institute the claim against the insurer of any one of such motor vehicles or
motorcycles unless the insurers agree among themselves that one of them will
accept and pay the claim initially.
(3) An applicant who is a named insured or a
relative of a named insured, other than the occupant of a motorcycle, and who
sustains a personal injury arising out of the use or operation of a motor
vehicle outside of New York State, shall institute the claim against the
insurer of the named insured or the insurer of the relative. Where there is
more than one insurer which would be the source of benefits, the insurers may
agree among themselves, if there is a valid basis therefor, that one of them
will accept and pay the claim initially. If there is no such agreement, the
provisions of subdivisions (b) and (e) of this section shall apply.
(4) An applicant who is a named insured or a
relative of a named insured, other than the occupant of a motorcycle, and who
sustains a personal injury arising out of the use or operation of an uninsured
motor vehicle in New York State, shall institute the claim against the insurer
of the named insured or the insurer of the relative. Where there is more than
one insurer which would be the source of benefits, the insurers may agree among
themselves, if there is a valid basis therefor, that one of them will accept
and pay the claim initially. If there is no such agreement, the provisions of
subdivisions (b) and (e) of this section shall apply. If there is no such
insurer and the accident occurs in New York State, then an applicant who is a
qualified person as defined in article 52 of the Insurance Law shall institute
the claim against the MVAIC.
(5) An
applicant who is neither an operator nor an occupant of a motor vehicle or a
motorcycle, and who sustains a personal injury arising out of the use or
operation in New York State of an insured motorcycle, shall institute the claim
against the insurer of the motorcycle.
(6) An applicant who is a named insured or a
relative of a named insured, other than the occupant of a motor vehicle or a
motorcycle, and who sustains a personal injury arising out of the use or
operation of an uninsured motorcycle in New York State shall institute the
claim against the insurer of the named insured or the insurer of the relative.
Where there is more than one insurer which would be the source of benefits, the
insurers may agree among themselves, if there is a valid basis therefor, that
one of them will accept and pay the claim initially. If there is no such
agreement, the provisions of subdivisions (b) and (e) of this section shall
apply. If there is no such insurer and the accident occurs in New York State,
then an applicant who is a qualified person as defined in article 52 of the
Insurance Law shall institute the claim against the MVAIC.
(7) An applicant who is a named insured or a
relative of a named insured, other than the occupant of a motor vehicle or a
motorcycle, and who sustains a personal injury arising out of the use or
operation of a motorcycle outside of New York State shall institute the claim
against the insurer of the named insured or relative. Where there is more than
one insurer which would be the source of benefits, the insurers may agree among
themselves, if there is a valid basis therefor, that one of them will accept
and pay the claim initially. If there is no such agreement, the provisions of
subdivisions (b) and (e) of this section shall apply.
(8) An applicant who is a New York State
resident and who is neither a named insured or relative under any mandatory
personal injury protection endorsement nor the owner of an uninsured motor
vehicle and who sustains a personal injury arising out of the use or operation
of a New York insured motor vehicle outside of New York State shall institute
the claim against the insurer of such motor vehicle. Where there is more than
one insurer that would be the source of benefits, the insurers may agree among
themselves, if there is a valid basis therefor, that one of them will accept
and pay the claim initially. If there is no such agreement, the provisions of
subdivisions (b) and (e) of this section shall apply.
(9) An applicant, other than an operator,
owner, or employee of the owner or operator of a bus or school bus, who, while
an occupant of such bus or school bus, sustains a personal injury arising out
of the use or operation in New York State of such bus or school bus, shall
institute the claim against the applicant's own insurer. If the applicant does
not have an insurer, the applicant shall institute the claim against the
insurer of the bus or school bus.
(10) An applicant who is an operator, owner,
or employee of the operator or owner of a bus or school bus, and who, while an
occupant of such bus or school bus, sustains a personal injury arising out of
the use or operation of such bus or school bus, shall institute the claim
against the insurer of such bus or school bus.
(b)
(1) If
a dispute regarding priority of payment arises among insurers who otherwise are
liable for the payment of first-party benefits, or if a dispute arises among
insurers who are liable for the payment of first-party benefits and have the
same priority of payment, then the first insurer to whom notice of claim is
given pursuant to section
65-3.3 or
65-3.4(a) of this
Subpart, by or on behalf of an eligible injured person, shall be responsible
for payment to such person. Any such dispute shall be resolved in accordance
with the arbitration procedures established pursuant to section
5105 of the
Insurance Law and section
65-4.11 of this Part. Each insurer
that concludes that it was not the first insurer contacted to provide first
party benefits shall issue a denial of claim form (NF-10) that includes the
following statement in box 33:
If, after contacting the insurer that we advised you has
primary responsibility for the payment of first party benefits, that insurer
denies coverage for your claim, you have the option to submit this dispute for
expedited arbitration by providing a copy of the denial form and a written
request along with a $40 filing fee to the organization listed under option two
on the back of this form. Your $40 filing fee will be refunded to you by the
insurer determined to be responsible for processing your claim. This
arbitration is limited solely to determining the insurer to process your claim,
and it will not resolve issues regarding pending bills or consider any other
defense to payment. You do not need to submit bills for this
arbitration.
(2)
(i) Under section
5106
(d)(2) of the Insurance Law, a group policy
issued pursuant to section
3455 or
3458 of the
Insurance Law shall provide first party benefits when a dispute exists as to
whether a driver was using or operating a motor vehicle in connection with a
transportation network company or peer-to-peer car sharing program
administrator when loss, damage, injury, or death occurs. Section
5106
(d)(2) of the Insurance Law requires a
transportation network company or peer-to-peer car sharing program
administrator to notify the insurer that issued the owner's policy of liability
insurance of the dispute within 10 business days of becoming aware that the
dispute exists. When there is a dispute, the group insurer liable for the
payment of first party benefits under a group policy shall have the right to
recover the amount paid from the driver's insurer or in the case of a
peer-to-peer car sharing program, the shared vehicle owner's insurer to the
extent that the driver would have been liable to pay damages in an action at
law.
(ii) Any such dispute shall be
resolved in accordance with the arbitration procedures established pursuant to
section 65-4.11 of this Part.
(iii) Each insurer that is not the insurer
that issued the group policy shall issue a denial of claim form (NF-10) that
includes in box 33 the statement set forth in paragraph (1) of this
subdivision.
(3) With
respect to any accident, insured event, or occurrence prior to January 1, 2019,
where the driver was using or operating a motor vehicle in connection with a
transportation network company when loss, damage, injury, or death occurs:
(i) an insurer that issued a group policy
pursuant to section
3455 of the
Insurance Law shall not seek to recover any amount that it pays pursuant to
article 51 of the Insurance Law from the insurer that issued the owner's policy
of liability insurance issued in satisfaction of the minimum requirements of
article 6 of the Vehicle and Traffic Law; and
(ii) If an insurer that issued the owner's
policy of liability insurance issued in satisfaction of the minimum
requirements of article 6 of the Vehicle and Traffic Law receives the claim
first, the insurer that issued a group policy pursuant to section
3455 of the
Insurance Law shall fully indemnify the insurer that issued the owner's policy
of liability insurance for amounts that it pays pursuant to article 51 of the
Insurance Law.
(4) With
respect to any accident, insured event, or occurrence, where the shared vehicle
driver was using or operating a motor vehicle pursuant to article 40 of the
General Business Law when loss, damage, injury, or death occurs:
(i) an insurer that issued a group policy
pursuant to section
3458 of the
Insurance Law shall not seek to recover any amount that it pays pursuant to
article 51 of the Insurance Law from the insurer that issued the owner's policy
of liability insurance issued in satisfaction of the minimum requirements of
article 6 of the Vehicle and Traffic Law; and
(ii) if an insurer that issued the owner's
policy of liability insurance issued in satisfaction of the minimum
requirements of article 6 of the Vehicle and Traffic Law receives the claim
first, the insurer that issued a group policy pursuant to section
3458 of the
Insurance Law shall fully indemnify the insurer that issued the owner's policy
of liability insurance for amounts that it pays pursuant to article 51 of the
Insurance Law.
(c) If the source of first-party benefits is
at issue because the status of the injured person as a pedestrian or an
occupant of a motor vehicle is in dispute, the insurer to whom notice of claim
was given or if such notice was given to more than one insurer, the first
insurer to whom notice was given shall, within 15 calendar days after receipt
of notice, obtain an agreement with the other insurer or insurers as to which
insurer will furnish no-fault benefits. If such an agreement is not reached
within the aforementioned 15 days, then the insurer to whom such notice was
first given shall process the claim and pay first-party benefits and resolve
the dispute in accordance with the arbitration procedures established pursuant
to section
5105 of the
Insurance Law and section
65-4.11 of this Part. Each insurer
that concludes that it was not the first insurer contacted to provide first
party benefits shall issue a denial of claim form (NF-10) that includes the
following statement in box 33:
If, after contacting the insurer that we advised you has
primary responsibility for the payment of first party benefits, that insurer
denies coverage for your claim, you have the option to submit this dispute for
expedited arbitration by providing a copy of the denial form and a written
request along with a $40 filing fee to the organization listed under option two
on the back of this form. Your $40 filing fee will be refunded to you by the
insurer determined to be responsible for processing your claim. This
arbitration is limited solely to determining the insurer to process your claim,
and it will not resolve issues regarding pending bills or consider any other
defense to payment. You do not need to submit bills for this
arbitration.
(d) The insurer
of the named insured or relative shall be responsible for the payment of first-
party benefits to such person when he/she is injured through the use or
operation of another motor vehicle, the alleged insurer of which has denied
coverage claiming it did not have a policy in force on such vehicle on the
accident date; provided, however, that the named insured or relative injured in
the accident was not the owner of the alleged uninsured motor vehicle. Payment
by the insurer of the named insured or relative shall not affect any legal
right of such insurer to challenge the validity of the denial by the other
insurer.
(e) Any insurer paying
first-party benefits shall be reimbursed by other insurers for their
proportionate share of the costs of the claim and the allocated expenses of
processing the claim, in accordance with the provisions entitled "other
coverage" contained in section
65-1.1 of this Part and provisions
entitled "other sources of first-party benefits" contained in Subpart 65-2 of
this Part.
(f) For the purposes of
this section, "insurer of such motor vehicle" means any insurer that is
providing first party benefits at the time the personal injury is
sustained.
