reglab/statecodes huggingface dataset:
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.3 - Notice

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If the
					 applicant's written notice of a claim, required by section
					 65-2.4  of
					 this Part and the mandatory and additional personal injury protection
					 endorsements, is given to a designated agent of an insurer or to a person
					 authorized to receive service of summons, the insurer is deemed to have
					 received the notice; provided, however, that unless otherwise provided by law
					 or contract, notice to the agent shall not be notice to the insurer if the
					 agent promptly notifies the applicant that the agent is not authorized to
					 receive notice of a claim.
(b) If
					 the agent is permitted to receive a notice of a claim, the agent may
					 acknowledge receipt of such notice in the manner set forth in this
					 section.
(c) Receipt of a
					 Department of Motor Vehicles Accident Report 104 (MV 104), or other accident
					 report indicating injuries to eligible injured persons, shall be deemed written
					 notice of a claim.
(d) The written
					 notice required by section
					 65-2.4  of
					 this Part and the mandatory and additional personal injury protection
					 endorsement(s) shall be deemed to be satisfied by the insurer's receipt of a
					 completed prescribed application for motor vehicle no-fault benefits (NYS form
					 N-F 2) forwarded to the applicant pursuant to section
					 65-3.4(b) 
					 of this Subpart or by the insurer's receipt of a completed hospital facility
					 form (NYS form N-F 5).
(e) When an
					 insurer denies a claim based upon the failure to provide timely written notice
					 of claim or timely submission of proof of claim by the applicant, such denial
					 must advise the applicant that late notice will be excused where the applicant
					 can provide reasonable justification of the failure to give timely
					 notice.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.4 - Acknowledgment of claim

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Whenever
					 the insurer receives notice of claim by telephone, the party receiving such
					 notice on behalf of the insurer shall be identified to the caller by name and
					 title and shall request the name, address and telephone number of the applicant
					 and the name of the policyholder or the policy number or both, if available,
					 along with reasonably obtainable information regarding the time, place and
					 circumstances of the accident which will enable the insurer to begin processing
					 the claim.
(b) Unless the insurer
					 will pay the claim as submitted within 30 calendar days, then, within five
					 business days after notice is received by the insurer at the address of its
					 proper claim processing office, either orally pursuant to subdivision (a) of
					 this section or in any other manner, the insurer shall forward to the applicant
					 the prescribed application for motor vehicle no-fault benefits (NYS form N-F 2)
					 accompanied by the prescribed cover letter (NYS form N-F 1). If notice is
					 initially received by the insurer at an address other than the proper claims
					 processing office, the five-day period for forwarding of the prescribed forms
					 shall commence on the day such notice is received at the proper claims
					 processing office, but in no event shall the prescribed forms be forwarded
					 later than 10 business days after receipt of the original notice.
(c) Attached is an appendix (Appendix 13,
					 infra), which includes the following prescribed claim forms that must be used
					 by all insurers, and shall not be altered unless approved by the
					 superintendent:
(1) Cover letter (NYS form
					 N-F 1A)--to be used with policies effective on or after September 1,
					 2001.
(2) Cover letter (NYS form
					 NF-1B)--to be used with policies effective prior to September 1,
					 2001.
(3) Application for motor
					 vehicle no-fault benefits (NYS form NF-2).
(4) Verification of treatment by attending
					 physician or other provider of health service (NYS form NF-3).
(5) Verification of hospital treatment (NYS
					 form NF-4).
(6) Hospital facility
					 form (NYS form NF-5).
(7)
					 Employer's wage verification report (NYS form NF-6).
(8) Verification of self-employment income
					 (NYS form NF-7).
(9) Agreement to
					 pursue social security disability benefits (NYS form NF-8).
(10) Agreement to pursue workers'
					 compensation or New York State disability benefits (NYS form NF-9).
(11) Denial of claim form (NYS form
					 NF-10).
(12) Subrogation agreement
					 (NYS form NF-11).
(13) Lump-sum
					 settlement agreement (NYS form NF-12).
(14) Election-optional basic economic loss
					 (NYS form NF-13).
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.6 - Follow-up requirements

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Application for motor vehicle no-fault benefits. At a minimum, the insurer
					 shall, within 10 calendar days, mail a second application for motor vehicle
					 no-fault benefits, with the prescribed cover letter, to the eligible injured
					 person or such person's attorney if, 30 calendar days after the original
					 mailing, a prescribed application has not been completed and returned to the
					 insurer. If the follow-up is sent to the applicant's attorney, a copy of the
					 prescribed cover letter, marked "second notice," shall be forwarded to the
					 applicant.
(b) Verification
					 requests. At a minimum, if any requested verifications has not been supplied to
					 the insurer 30 calendar days after the original request, the insurer shall,
					 within 10 calendar days, follow up with the party from whom the verification
					 was requested, either by telephone call, properly documented in the file, or by
					 mail. At the same time the insurer shall inform the applicant and such person's
					 attorney of the reason(s) why the claim is delayed by identifying in writing
					 the missing verification and the party from whom it was requested.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.7 - Election

Current through Register Vol. 46, No. 28, July 10, 2024
(a) If an insured
					 has purchased optional basic economic loss (OBEL) coverage pursuant to section 5102 (a)(5)  of the
					 Insurance Law, the insurer shall notify each eligible injured person (or that
					 person's legal representative) making a claim under such policy that such
					 person may elect how OBEL coverage will be applied.
(b) The insurer shall mail form NYS form
					 NF-13 to the eligible injured person or that person's legal representative as
					 soon as, and in no event later than 15 calendar days after, the insurer has
					 received claims aggregating $30,000 in basic economic loss.
(c) If the eligible injured person or that
					 person's legal representative does not return the election form (NYS form
					 NF-13) within 15 calendar days after the initial mailing, then within five
					 calendar days after such time has elapsed the insurer shall mail to the
					 eligible injured person or that person's legal representative a second election
					 notice, clearly marked "SECOND NOTICE."
(d) Failure of the eligible injured person or
					 that person's legal representative to respond to the second notice within 15
					 calendar days after its mailing shall be considered an election by the eligible
					 injured person to apply OBEL coverage to all elements of basic economic
					 loss.
(e) Once made by the eligible
					 injured person or that person's legal representative, an OBEL election cannot
					 be changed, except that, if claims payable under OBEL coverage have not yet
					 been received by the company, an eligible injured person who has failed to
					 respond to the second notice in a timely manner may make an election.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.8 - Payment or denial of claim (30-day rule)

Current through Register Vol. 46, No. 28, July 10, 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.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.9 - Interest on overdue payments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) All overdue mandatory and additional
					 personal injury protection benefits due an applicant or assignee shall bear
					 interest at a rate of two percent per month, calculated on a pro-rata basis
					 using a 30-day month. When payment is made on an overdue claim, any interest
					 calculated to be due in an amount exceeding $5 shall be paid to the applicant
					 or the applicant's assignee without demand therefor.
(b) The insurer shall not suggest or require,
					 as a condition to settlement of a claim, that the interest due be
					 waived.
(c) If an applicant does
					 not request arbitration or institute a lawsuit within 30 days after the receipt
					 of a denial of claim form or payment of benefits calculated pursuant to
					 Department of Financial Services regulations, interest shall not accumulate on
					 the disputed claim or element of claim until such action is taken. If any
					 applicant is a member of a class in a class action brought for payment of
					 benefits, but is not a named party, interest shall not accumulate on the
					 disputed claim or element of claim until a class that includes such applicant
					 is certified by court order, or such benefits are authorized in that action by
					 Appellate Court decision, whichever is earlier.
(d) If an applicant has submitted a dispute
					 to arbitration or the courts, interest shall accumulate, unless the applicant
					 unreasonably delays the arbitration or court proceeding.
(e) The insurer shall separately identify any
					 interest payment on an overdue claim from benefit payments. This may be done by
					 issuing separate drafts for each amount or by an accompanying statement that
					 clearly and separately identifies the components of the draft.
(f) An insurer may not include in its rate
					 making calculations any interest paid on an overdue claim.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.10 - Attorneys

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An applicant or
					 an assignee shall be entitled to recover their attorney's fees, for services
					 necessarily performed in connection with securing payment, if a valid claim or
					 portion thereof was denied or overdue. If such a claim was initially denied and
					 subsequently paid by the insurer, the attorney's fee shall be $80. If such a
					 claim was overdue but not denied, the attorney's fee shall be equal to 20
					 percent of the amount of the first-party benefits and any additional
					 first-party benefits plus interest payable pursuant to section 65- 3.9 of this
					 Subpart, subject to a maximum fee of $60.
(b) If a dispute is resolved in accordance
					 with any of the optional arbitration procedures contained in this Part, either
					 during the initial review by the Department of Financial Services or by an
					 arbitration award, and if payment is not made by the insurer in accordance with
					 the terms specified in the conciliation letter or arbitration award within 45
					 days following such resolution, an additional attorney's fee shall be paid by
					 the insurer when the attorney writes to the insurer in order to receive such
					 overdue payment. The additional attorney's fee shall be $60 and shall become
					 payable only after written request from the attorney to the insurer, received
					 by the insurer more than 45 days after mailing of the conciliation letter or
					 arbitration award. Such fee shall not be payable if payment was made by the
					 insurer prior to the attorney's request for such payment or if an arbitration
					 award is appealed in accordance with the provisions of this Part.
(c) The insurer shall segregate any
					 attorney's fee on an overdue claim from the loss and interest payments, either
					 through issuance of separate drafts or through an accompanying statement which
					 clearly and separately identifies the components of the draft.
(d) No attorney's fee payable by an insurer
					 on account of an overdue claim may be included by the insurer in any rate
					 making calculations.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.11 - Direct payments

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An
					 insurer shall pay benefits for any element of loss other than death benefits,
					 directly to the applicant or, when appropriate, to the applicant's parent or
					 legal guardian or to any person legally responsible for necessities, or, upon
					 assignment by the applicant or any of the aforementioned persons, shall pay
					 benefits directly to providers of health care services as covered under section 5102 (a)(1)  of the
					 Insurance Law, or to the applicant's employer for loss of earnings from work as
					 authorized under section 5102 (a)(2)  of the
					 Insurance Law. Death benefits shall be paid to the estate of the eligible
					 injured person.
(b) In order for a
					 health care provider/hospital to receive direct payment from the insurer, the
					 health care provider or hospital must submit to the insurer:
(1) a properly executed authorization to pay
					 benefits as contained on NYS form NF-3, NF-4 or NF-5 or other claim form
					 acceptable to the insurer. Execution of an authorization to pay benefits shall
					 not constitute or operate as a transfer of all rights from the eligible injured
					 person to the provider; or
(2) a
					 properly executed assignment on:
(i) the
					 prescribed verification of treatment by attending physician or other provider
					 of service form (NYS form NF-3); or
(ii) the prescribed verification of hospital
					 treatment form (NYS form NF-4), or the prescribed hospital facility form (NYS
					 form NF-5); or
(iii) the prescribed
					 no-fault assignment of benefits form (NYS form NF-AOB) contained in Appendix
					 13, infra, or an equivalent form containing nonsubstantive enhancements, but no
					 changes may be made to the assignment language itself.
With respect to health care providers, other than
						hospitals, the use of revised form NF-3 is applicable to all claims arising
						from motor vehicle accidents, which occur on and after March 1, 2002. With
						respect to hospitals, the use of revised forms NF-4 and NF-5 is applicable to
						all claims arising from motor vehicle accidents, which occur on and after
						September 1, 2002.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.14 - Scope of coverage

Current through Register Vol. 46, No. 28, July 10, 2024
(a) An
					 insurer shall be liable only for the payment of benefits for losses caused by
					 the accident, including those caused by the aggravation of preexisting
					 conditions.
(b) An insurer shall
					 pay benefits to an applicant for losses arising out of an accident in the
					 following situations:
(1) where coverage has
					 been excluded for an applicant operating a vehicle while in an intoxicated
					 condition or while the applicant's ability is impaired by the use of a drug, if
					 such intoxicated or drugged condition was not a contributing cause of the
					 accident causing the injuries;
(2)
					 where coverage has been excluded for an applicant operating or occupying a
					 motor vehicle known to the applicant to be stolen, and the applicant is an
					 involuntary operator or occupant of said vehicle;
(3) where there is no physical contact
					 between the applicant and a motor vehicle or motorcycle which is the proximate
					 cause of the injury;
(4) where the
					 motor vehicle or motorcycle is used without the specific permission of the
					 owner, but is not a stolen vehicle; or
(5) where the accident arises out of
					 repairing, servicing or otherwise maintaining a motor vehicle or a motorcycle,
					 other than in the course of a business, and for which no charge or fee is
					 contemplated.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.15 - Computation of basic economic loss

Current through Register Vol. 46, No. 28, July 10, 2024
When claims aggregate to more than $50,000, payments for
						basic economic loss shall be made to the applicant and/or an assignee in the
						order in which each service was rendered or each expense was incurred, provided
						claims therefor were made to the insurer prior to the exhaustion of the
						$50,000. If the insurer pays the $50,000 before receiving claims for services
						rendered prior in time to those which were paid, the insurer will not be liable
						to pay such late claims. If the insurer receives claims of a number of
						providers of services, at the same time, the payments shall be made in the
						order of rendition of services.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.17 - Explanation of benefits

Current through Register Vol. 46, No. 28, July 10, 2024
At least for every six month period during which any
						benefits are paid, the insurer shall forward an explanation of benefits (EOB)
						to the eligible injured person and such person's attorney. The first six month
						period shall commence on the date of the accident and the EOB shall be mailed
						within 60 days of the conclusion of the period selected by the insurer. Such
						EOB shall include, at a minimum, the name of the payee, a description of the
						service or benefit claimed and the amount paid. It shall also include the fraud
						warning statement prescribed on the application for motor vehicle no-fault
						benefits (NYS form NF-2) contained in Appendix 13, infra, and the name, address
						and telephone number of the insurer representative to whom questions should be
						directed.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.18 - Releases

Current through Register Vol. 46, No. 28, July 10, 2024
Except as provided in section
						65-3.16(b)(13) 
						of this Subpart (lump-sum settlements), there shall be no settlement nor any
						release, express or implied, for mandatory or optional personal injury
						protection benefits (mandatory PIP or additional PIP
						benefits).
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.19 - Offsets

Current through Register Vol. 46, No. 28, July 10, 2024
(a) State or
					 Federal Workers' Compensation Law benefits that are to be deducted from
					 first-party benefits or additional first-party benefits in accordance with this
					 Part shall not include payments made under any Workers' Compensation Law of the
					 Dominion of Canada or any of its provinces.
(b) Federal social security disability
					 benefits that are to be deducted from first-party or additional first-party
					 benefits shall include, but not be limited to, disability benefits provided for
					 under the Railroad Retirement Act.
(c)
(1) If
					 any source of workers' compensation benefits, or disability benefits under
					 article 9 of the Workers' Compensation Law, denies liability for payment of
					 benefits, in whole or in part, the insurer responsible for the payment of
					 first-party or additional first-party benefits shall pay benefits without
					 deducting the withheld workers' compensation or disability benefits; provided,
					 however, that the applicant executes a prescribed agreement to pursue workers'
					 compensation or New York State disability benefits (NYS form NF-9), which shall
					 obligate the applicant to diligently pursue the claim and to repay first-party
					 benefits equal to the withheld amounts in the event such amounts are eventually
					 paid to the applicant. The insurer is entitled to independent verification of
					 the claim in accordance with this Subpart. If the applicant paid an attorney's
					 fee out of the proceeds of the award, pursuant thereto, the amount of the
					 attorney's fee shall be deducted from the repayment.
(2) The insurer should send a copy of the
					 completed agreement to the local district office of the Workers' Compensation
					 Board nearest the applicant's residence. Thereafter, the Workers' Compensation
					 Board will give the insurer notice of the applicant's hearing, so that the
					 insurer may be present. Although the insurer may not be a party to such
					 hearing, it may submit evidence to the referee and may request that the referee
					 put specific questions to the parties.
(3) If the applicant will not execute the
					 agreement and the automobile insurer is held ultimately liable, such insurer
					 shall not on that account be responsible for the payment of an attorney's fee
					 or interest on the late payment. To the extent that any reimbursement due the
					 insurer is not made by the applicant, the insurer may thereafter deduct such
					 amounts from any future first-party benefits due on the claim.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-3 - Claims For Personal Injury Protection Benefits › Section 65-3.20 - Reimbursement and trust agreement

Current through Register Vol. 46, No. 28, July 10, 2024
An insurer may request that an applicant assign to the
						insurer such applicant's right to commence an action, pursuant to section 5104 (b)  of the Insurance
						Law, before two years after the accrual thereof; provided, however, that such
						request must be accompanied by a clear, detailed explanation that the applicant
						has the right to refuse such request and that such refusal will not prejudice
						the applicant's eligibility for the payment of any first-party benefits to
						which the applicant is entitled. If, as a result of such assignment, the
						insurer recovers an amount in excess of the amount paid or payable to the
						applicant in first-party benefits, such excess amount shall be remitted to the
						applicant less a pro rata share of collection costs.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.1 - Applicability of arbitration procedures under article 51 of the insurance law

Current through Register Vol. 46, No. 28, July 10, 2024
This Subpart shall apply to insurers, and the term
						insurer, as used in this Subpart, shall include both insurers and
						self-insurers, as those terms are defined in this Part and article 51 of the
						Insurance Law, and shall also include the Motor Vehicle Accident
						Indemnification Corporation (MVAIC) created pursuant to article 52 of the
						Insurance Law and any company or corporation providing insurance pursuant to
						section 5103 (g)  of the Insurance
						Law.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.2 - Initiation of optional arbitration procedures under section 5106(b) of the insurance law for arbitrations filed with an organization designated by the superintendent on and after december 1, 1999

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Administration by an organization designated by the superintendent.
(1) Section 5106  of the Insurance Law requires that the
					 Superintendent of Insurance promulgate simplified procedures for the resolution
					 by arbitration of no-fault disputes.
(2) Chapter 892 of the Laws of 1977 provides
					 for the establishment of revised optional arbitration systems for the
					 resolution of no-fault disputes. These changed procedures for the
					 administration of the arbitration system provide for initial review of all
					 arbitration requests by an organization designated by the superintendent. The
					 designated organization, acting on behalf of the superintendent, is authorized
					 to receive, attempt to conciliate and forward to arbitration all requests for
					 arbitration that it cannot conciliate.
(3) All optional arbitrations pursuant to
					 section 5106 (b)  of the Insurance
					 Law will be administered by an organization designated by the
					 superintendent.
(4) No-fault
					 optional arbitration advisory committee. The superintendent shall select an
					 advisory committee composed of 12 members to review the operations and the
					 actual costs of the optional arbitration procedures set forth in this Subpart.
					 Not more than four of the members of the advisory committee shall be
					 representatives of self-insurers.
(5) Oversight. The superintendent shall
					 oversee the operation procedures of the designated organization with respect to
					 the administration of the optional arbitration process. Such oversight shall
					 include, but not be limited to, access to all systems, databases, and records
					 related to the optional arbitration process. In addition, the designated
					 organization shall make reports to the superintendent in whatever form the
					 superintendent shall prescribe.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.3 - Jurisdiction of arbitration forums

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Insurance
					 Department Arbitration (IDA) forum. IDA jurisdiction shall be limited to
					 requests for no-fault arbitration filed prior to December 1, 1999 and shall
					 include only those disputes where the remaining issues after expiration of the
					 conciliation period involve:
(1) correct
					 computation of health service provider fees, whether or not such fees are
					 specifically covered by the fee schedules promulgated in Part 68 of this Title
					 (Regulation 83);
(2) where the
					 amount in dispute is less than $400 and such dispute does not involve a
					 coverage question or affect the outcome of any other portion of the applicant's
					 claim; or
(3) whether the claim was
					 overdue at the time it was paid, how long the claim was overdue, or whether the
					 correct amount of interest or attorney's fee on an overdue claim was
					 paid.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.5 - No-fault arbitration forum procedure

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Notice. If
					 a dispute has been transmitted for arbitration by the Insurance Department or
					 the conciliation center, the parties will be notified by the designated
					 organization, in writing, that the dispute will be resolved by arbitration. At
					 the arbitrator's discretion, if the dispute involves an amount less than
					 $2,000, the parties shall be notified that the dispute shall be resolved on the
					 basis of written submissions of the parties. All such submissions shall be
					 received by the designated organization within 30 calendar days of the date of
					 mailing of the notice. No oral arguments will be permitted, unless the
					 arbitrator determines that additional evidence or testimony is necessary. In
					 order to facilitate receipt of evidence by the designated organization, the
					 parties may forward their submissions prior to receipt of the above
					 notification.
(b) Special expedited
					 arbitration.
(1) Special expedited
					 arbitration shall be available for disputes involving:
(i) the failure to submit notice of claim
					 within 30 calendar days after the accident and where it has been determined by
					 the insurer that reasonable justification for late notice has not been
					 established; and
(ii) the proper
					 application of sections
					 65-3.12(b)
					 and (c) and
					 65-3.13(a)(2)-(4)
					 and (6)  of this Part.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.7 - Independent health consultant

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
					 designated organization shall maintain a list of independent health
					 consultants, who will review medical evidence or examine the eligible injured
					 person upon the request of any arbitrator designated pursuant to this
					 Subpart.
(b) The independent health
					 consultant shall be selected by the designated organization from its list and,
					 to the extent practicable, shall be a specialist in the field requested by the
					 arbitrator. If a medical examination is requested by the arbitrator, such
					 examination shall be conducted at the health consultant's office, which shall
					 be located in the general locale of the applicant's residence, or at a place
					 agreed upon by the parties and the consultant.
(c) Within 15 calendar days after the review
					 of medical evidence or examination of the eligible injured person, the health
					 consultant shall submit to the designated organization a written report which
					 shall contain the consultant's advisory opinion for consideration by the
					 arbitrator. The designated organization shall submit such report to the
					 arbitrator and the parties.
(d) The
					 independent health consultant's fee shall include the written report and be
					 paid by the designated organization, with the cost of such fee charged as an
					 administrative expense of the no- fault arbitration forum.
(e) No person shall serve as an independent
					 health consultant in any arbitration in which such person has any financial or
					 personal interest or bias. An independent health consultant shall disclose to
					 the designated organization any circumstance which is likely to create an
					 appearance of bias or which might serve to disqualify such expert. Upon receipt
					 of such information, the designated organization shall immediately disclose it
					 to the parties. If a party challenges a health consultant, the specific grounds
					 for the challenge shall be submitted in writing. The designated organization
					 shall determine whether the health consultant should be disqualified and shall
					 inform the parties of its decision, which shall be final and binding. If a
					 health consultant should resign, be disqualified or be otherwise unable to
					 perform necessary duties, the designated organization shall appoint another
					 health consultant to the case.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.8 - Witness fees

Current through Register Vol. 46, No. 28, July 10, 2024
(a) No witness
					 fee shall be payable to a person who is a party to the arbitration.
(b) The arbitrator shall not approve the
					 payment of a fee to a witness appearing on behalf of an applicant or an
					 assignee, unless the witness was subpoenaed by the arbitrator or, prior to
					 appearance, the witness's presence was determined by the arbitrator to be
					 necessary for resolution of the dispute.
(c) Whenever a witness fee is determined by
					 the arbitrator to be payable, the cost thereof shall be charged as an
					 administrative expense of the arbitration forum.
(d) Any witness fee awarded pursuant to
					 subdivisions (b) and (c) of this section shall be determined as follows:
(1) If the witness is testifying as an
					 expert, the fee shall be calculated on the basis of such witness's documented
					 usual and customary hourly charge for an appearance, plus necessary verified
					 disbursements.
(2) Any other
					 witness shall only be entitled to reimbursement for verified expenses and
					 economic losses necessarily incurred in connection with an appearance before
					 the arbitrator.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.9 - Serving of notice

Current through Register Vol. 46, No. 28, July 10, 2024
The IDA, the designated organization and the parties may
						use facsimile transmission, telex, telegram or other written or electronic
						forms of communication to give the notices required by this
						Subpart.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-4 - Arbitration › Section 65-4.10 - Master arbitration procedures under section 5106(b) of the insurance law

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
					 Grounds for review. An award by an arbitrator rendered pursuant to section 5106 (b)  of the Insurance
					 Law and section
					 65-4.4
					 or
					 65-4.5 
					 of this Subpart may be vacated or modified solely by appeal to a master
					 arbitrator, and only upon one or more of the following grounds:
(1) any ground for vacating or modifying an
					 award enumerated in article 75 of the Civil Practice Law and Rules (an article
					 75 proceeding), except the ground enumerated in CPLR subparagraph
					 7511(b)(1)(iv) (failure to follow article 75 procedure);
(2) that the award required the insurer to
					 pay amounts in excess of the policy limitations for any element of first-party
					 benefits; provided that, as a condition precedent to review by a master
					 arbitrator, the insurer shall pay all other amounts set forth in the award
					 which will not be the subject of an appeal, as provided for in section
					 65-4.4
					 or
					 65-4.5 
					 of this Subpart;
(3) that the award
					 required the insurer to pay amounts in excess of the policy limitations for any
					 element of additional first-party benefits (when the parties had agreed to
					 arbitrate the dispute under the additional personal injury protection
					 endorsement for an accident which occurred prior to January 1, 1982); provided
					 that, as a condition precedent to review by a master arbitrator, the insurer
					 shall pay all other amounts set forth in the award which will not be the
					 subject of the appeal, as provided for in section
					 65-4.4
					 or
					 65-4.5 
					 of this Subpart;
(4) that an award
					 rendered in an arbitration under section
					 65-4.4
					 or
					 65-4.5 
					 of this Subpart, was incorrect as a matter of law (procedural or factual errors
					 committed in the arbitration below are not encompassed within this
					 ground);
(5) that the attorney's
					 fee awarded by an arbitrator below was not rendered in accordance with the
					 limitations prescribed in section
					 65-4.6 
					 of this Subpart; provided that, as a condition precedent to review by a master
					 arbitrator, the insurer shall pay all other amounts set forth in the award
					 which will not be the subject of the appeal, as provided for in section
					 65-4.4
					 or
					 65-4.5 
					 of this Subpart.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-5 - Unauthorized Providers Of Health Services › Section 65-5.0 - Preamble

Current through Register Vol. 46, No. 28, July 10, 2024
(a) For years,
					 certain owners and operators of professional service corporations or other
					 similar business entities have abused the no-fault insurance system. These
					 persons are involved in activities that include intentionally staging accidents
					 and billing no-fault insurers for health services that were unnecessary or
					 never in fact rendered. This fraud costs no-fault insurers tens if not hundreds
					 of millions of dollars, which insurers ultimately pass on to New York consumers
					 in the form of higher automobile insurance premiums. It also threatens the
					 affordability of health care and the public's health, safety, and
					 welfare.
(b) Insurance Law section
					 5109 requires the Superintendent of Financial Services, in consultation with
					 the Commissioner of Health and the Commissioner of Education, to establish
					 standards and procedures for the investigation and suspension or removal of a
					 provider of health services' authorization to demand or request payment for
					 health services provided under Insurance Law article 51. This Subpart
					 implements Insurance Law section 5109.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-5 - Unauthorized Providers Of Health Services › Section 65-5.1 - Definitions

Current through Register Vol. 46, No. 28, July 10, 2024
As used in this Subpart, the following terms shall have
						the meaning ascribed to them:
(a)
					 Health services or medical services means services, supplies, therapies, or
					 other treatments as specified in Insurance Law section 5102(a)(1)(i), (ii), or
					 (iv).
(b) Insurer shall have the
					 meaning set forth in Insurance Law section 5102(g), and also shall include the
					 motor vehicle accident indemnification corporation and any company or
					 corporation providing coverage for basic economic loss, as defined in Insurance
					 Law section 5102(a), pursuant to Insurance Law section 5103(g).
(c) Noticing commissioner means the
					 Commissioner of Health or the Commissioner of Education, whomever sends a
					 notice of hearing under this Subpart.
(d) Provider of health services or provider
					 means a person or entity who or that renders or has rendered health
					 services.
(e) Superintendent means
					 the Superintendent of Financial Services.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-5 - Unauthorized Providers Of Health Services › Section 65-5.2 - Investigations

Current through Register Vol. 46, No. 28, July 10, 2024
(a) The
					 superintendent may investigate any reports made pursuant to Insurance Law
					 section 405, allegations, or other information in the superintendent's
					 possession, regarding providers of health services engaging in any of the
					 unlawful activities set forth in Insurance Law section 5109(b). After
					 conducting an investigation, the superintendent will send to the Commissioner
					 of Health or the Commissioner of Education, as appropriate, a list of any
					 providers who or that the superintendent believes may have engaged in any of
					 the unlawful activities set forth in Insurance Law section 5109(b), together
					 with a description of the grounds for inclusion on the list. Within 45 days of
					 receipt of the list, the Commissioner of Health or Commissioner of Education
					 shall notify the superintendent in writing whether he or she confirms that the
					 superintendent has a reasonable basis to proceed with notice and a hearing for
					 determining whether any of the listed providers should be deauthorized from
					 demanding or requesting any payment for medical services in connection with any
					 claim under Insurance Law article 51.
(b) The Commissioner of Health and the
					 Commissioner of Education also may investigate any reports, allegations, or
					 other information in their possession, regarding providers engaging in any of
					 the unlawful activities set forth in Insurance Law section 5109(b). If either
					 commissioner conducts an investigation, then that commissioner, or the
					 superintendent, if requested by the commissioner, shall be responsible for
					 providing notice and an opportunity to be heard to the providers of health
					 services that they are subject to deauthorization from demanding or requesting
					 any payment for medical services in connection with any claim under Insurance
					 Law article 51. Nothing in this section, however, shall preclude the
					 superintendent, Commissioner of Health, or Commissioner of Education from
					 conducting joint investigations and hearings, or the Commissioner of Health or
					 Commissioner of Education from conducting professional misconduct proceedings
					 against the providers of health services pursuant to the Public Health Law or
					 title VIII of the Education Law.
New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter III - Policy and Certificate Provisions › Subchapter B - Property and Casualty Insurance › Part 65 - Regulations Implementing The Comprehensive Motor Vehicle Insurance Reparations Act › Subpart 65-5 - Unauthorized Providers Of Health Services › Section 65-5.3 - Notice; how given

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
(1) The superintendent, Commissioner of
					 Health, or Commissioner of Education shall give notice of any hearing to a
					 provider at least 30 days prior to the hearing, in writing, either by
					 delivering it to the provider or by depositing the same in the United States
					 mail, postage prepaid, registered or certified, and addressed to the last known
					 place of business of the provider or if no such address is known, then to the
					 residence address of the provider.
(2) The notice shall refer to the applicable
					 provisions of the law under which action is proposed to be taken and the
					 grounds therefor, but failure to make such reference shall not render the
					 notice ineffective if the provider to whom it is addressed is thereby or
					 otherwise reasonably apprised of such grounds.
(3) It shall be sufficient for the
					 superintendent or noticing commissioner to give to the provider:
(i) notice of the time and the place at which
					 an opportunity for hearing will be afforded; and
(ii) if the person appears at the time and
					 place specified in the notice or any adjourned date, a hearing.