Current through Register Vol. 46, No. 39, September 25, 2024
(a)
(1)
No-fault benefits are overdue if not paid within 30 calendar days after the
insurer receives proof of claim, which shall include verification of all of the
relevant information requested pursuant to section
65-3.5 of this Subpart. In the
case of an examination under oath or a medical examination, the verification is
deemed to have been received by the insurer on the day the examination was
performed.
(2) An insurer shall
defer payment of OBEL benefits for claims submitted by or on behalf of the
eligible injured person until an OBEL option has been elected in accordance
with section
65-3.7 of this Subpart. An insurer
shall pay or deny such claims under OBEL coverage within 30 calendar days of
the date that an election has been made.
(b)
(1) An
insurer may not interrupt the payment of benefits for any element of basic or
extended economic loss pending the administering of a medical examination,
unless the applicant or the applicant's attorney is responsible for the delay
or inability to schedule the examination, in which case any denial of payment
shall be made only in accordance with policy provisions on a prescribed denial
of claim form (NYS form NF-10).
(2)
Notwithstanding paragraph (1) of this subdivision, if the insurer has
information which clearly demonstrates that the applicant is no longer
disabled, the insurer may discontinue the payment of benefits by forwarding to
the applicant a prescribed denial of claim form.
(3) Except as provided in subdivision (e) of
this section, an insurer shall not issue a denial of claim form (NYS form
NF-10) prior to its receipt of verification of all of the relevant information
requested pursuant to sections 65-3.5 and
65-3.6 of this Subpart (e.g.,
medical reports, wage verification, etc.). However, an insurer may issue a
denial if, more than 120 calendar days after the initial request for
verification, the applicant has not submitted all such verification under the
applicant's control or possession or written proof providing reasonable
justification for the failure to comply, provided that the verification request
so advised the applicant as required in section
65-3.5(o) of this
Subpart. This subdivision shall not apply to a prescribed form (NF-form) as set
forth in Appendix 13 of this Title, medical examination request, or examination
under oath request. This paragraph shall apply, with respect to claims for
medical services, to any treatment or service rendered on or after April 1,
2013, and with respect to claims for lost earnings and reasonable and necessary
expenses, to any accident occurring on or after April 1, 2013.
(4) If the specific reason for a denial of a
no-fault claim, or any element thereof, is a medical examination or peer review
report requested by the insurer, the insurer shall release a copy of that
report to the applicant for benefits, the applicant's attorney, or the
applicant's treating physician, upon the written request of any of these
parties.
(c) Within 30
calendar days after proof of claim is received, the insurer shall either pay or
deny the claim in whole or in part.
(1) If
the insurer denies a claim in whole or in part involving elements of basic
economic loss or extended economic loss, the insurer shall notify the applicant
or the authorized representative on the prescribed denial of claim form, in
duplicate, and shall furnish, if requested by the applicant, one copy of all
prescribed claim forms submitted by or on behalf of the applicant thereto.
However, where a denial involves a portion of a health provider's bill, the
insurer may make such a denial on a form or letter approved by the department
which is issued in duplicate. No form or letter shall be approved unless it
contains substantially the same information as the prescribed form which is
relevant to the claim denied.
(2)
Notwithstanding paragraph (1) of this subdivision, where there is a denial in
part of a medical bill as a result of charges not conforming to section
5108 of the
Insurance Law, an insurer may effect compliance with paragraph (1) of this
subdivision for those overcharges of $50 or less by telephone agreement with
the provider or provider's representative, with proper documentation of such
agreement in the claim file. The provider must have been entitled to direct
payment pursuant to section
65-3.11 of this Subpart.
(d) Where an insurer denies part
of a claim, it shall pay benefits for the undisputed elements of the claim.
Such payments shall be made without prejudice to either party.
(e) If an insurer has determined that
benefits are not payable for any of the following reasons:
(1) no coverage on the date of
accident;
(2) circumstances of the
accident not covered by no-fault; or
(3) statutory exclusions pursuant to section
5103
(b) of the Insurance Law; it shall notify the
applicant within 10 business days after such determination on a prescribed
denial of claim form, specifying the reasons for the denial. Failure by an
insurer to notify the applicant of its denial of the claim within the
10-business-day period after its determination shall not preclude the insurer
from asserting a defense to the claim which is based upon the reasons for such
denial.
(f) An insurer
shall be entitled to receive proper proof of claim and a failure to observe any
of the time frames specified in this section shall not prevent an insurer from
requiring proper proof of claim.
(g)
(1)
Proof of the fact and amount of loss sustained pursuant to Insurance Law
section 5106(a) shall not be deemed supplied by an applicant to an insurer and
no payment shall be due for such claimed medical services under any
circumstances:
(i) when the claimed medical
services were not provided to an injured party; or
(ii) for those claimed medical service fees
that exceed the charges permissible pursuant to Insurance Law section 5108(a)
and (b) and the regulations promulgated thereunder for services rendered by
medical providers.
(2)
This subdivision shall apply to medical services rendered on or after April 1,
2013.
(h) With respect
to a denial of claim (NYS form NF-10), an insurer's non-substantive technical
or immaterial defect or omission shall not affect the validity of a denial of
claim. This subdivision shall apply to medical services rendered, and to lost
earnings and other reasonable and necessary expenses incurred, on or after
April 1, 2013.
(i) Notwithstanding
subdivision (e) of this section, if an insurer has reason to believe that the
applicant was operating a motor vehicle while intoxicated or impaired by the
use of a drug, and such intoxication or impairment was a contributing cause of
the automobile accident, the insurer shall be entitled to all available
information relating to the applicant's condition at the time of the accident.
Proof of a claim shall not be complete until the information which has been
requested, pursuant to section
65-3.5(a) or (b)
of this Subpart, has been furnished to the insurer by the applicant or the
authorized representative.
(j)
Where the insurer has determined that a self-employed applicant's disability
arose from the claimed accident, the insurer shall be deemed to have proof of
claim for loss of earnings or substitute services, subject to receipt of
medical proof of disability for the period claimed, when it has received a
completed prescribed verification of self-employment income form (NYS form
NF-7) and the proof requested thereon. The insurer shall determine therefrom
the amount of loss of earnings benefits, if any, due the applicant.
Notwithstanding the above, if an insurer requires verification in addition to
the proof supplied, it may request such additional verification pursuant to
section 65- 3.5(b) of this Subpart.
(k) A death benefit claim will be deemed to
have been proven when the insurer receives a copy of the decedent's death
certificate and proof that the personal representative of the decedent's estate
was duly appointed in this State or any other jurisdiction.
(l) For the purposes of counting the 30
calendar days after proof of claim, wherein the claim becomes overdue pursuant
to section
5106 of the
Insurance Law, with the exception of section
65-3.6 of this Subpart, any
deviation from the rules set out in this section shall reduce the 30 calendar
days allowed.
Example:Where an insurer sends an application for motor
vehicle no-fault benefits 15 business days after notice is received at the
address of the insurer's proper claim processing office instead of five
business days, the 30 calendar days permitted by subdivision (a) of this
section are reduced to 20 calendar days.
