New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 3 - AUTOMOBILE INSURANCE › Subchapter 5 - PERSONAL INJURY PROTECTION DISPUTE RESOLUTION › Section 11:3-5.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Administrator" means the dispute resolution organization designated by the Commissioner pursuant to N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.3.
"Basic policy" means an automobile insurance policy issued pursuant to N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3.
"Commissioner" means the Commissioner of the New Jersey Department of Banking and Insurance.
"Control" or "controlled" means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership of voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person, directly or indirectly, owns, controls, holds the power to vote, or holds proxies representing, 10 percent or more of the voting securities of any other person, provided that no such presumption of control shall of itself relieve any person so presumed to have control from any requirement of P.L. 1970, c.22 (N.J.S.A. 17:27A-1 et seq.). This presumption may be rebutted by a showing made in the manner provided by N.J.S.A. 17:27A-3jthat control does not exist in fact. The Commissioner may determine, after furnishing all persons in interest notice and an opportunity to be heard, and making specific findings of fact to support such determination, that control exists in fact, notwithstanding the absence of a presumption to that effect.
"Department" means the New Jersey Department of Banking and Insurance.
"Dispute resolution organization" or "DRO" means an organization that meets the standards set forth in N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.4.
"Dispute resolution professional" or "DRP" means a natural person who meets the standards set forth in N.J.A.C. 11:3-5.5
"In-person proceeding" or "in-person case" means a PIP dispute where the parties or their representatives appear in person or telephonically before the DRP to present their cases in accordance with the rules of the dispute resolution organization.
"Medical review organization" or "MRO" means an organization of health care professionals who are licensed in New Jersey, which is certified by the Commissioner to engage in unbiased medical review of the medical care provided to persons injured in automobile accidents in accordance with N.J.S.A. 39:6A-5.2 and this subchapter. The term includes either;
1. Any peer review organization with which the Federal Health Care Financing Administration or the State contracts for medical review of Medicare or medical assistance services; or
2. Any independent health care review company.
"On-the-papers proceeding" or "on-the-papers case" means a PIP dispute where the parties or their representatives submit written documentation supporting their case and the DRP decides the case based solely upon the documentation without any in person or telephonic appearances by the parties or their representatives in accordance with the rules of the dispute resolution organization. On-the-papers proceedings are only permitted where all parties consent or where there is no further treatment at issue and the amount at issue in the dispute is less than $ 1,000.
"Personal Automobile Insurance Plan" or "PAIP" means the personal lines automobile insurance residual market mechanism established pursuant to N.J.S.A. 17:29D-1 by N.J.A.C. 11:3-2.
"Personal injury protection" or "PIP" means the coverage provided by a policy of automobile insurance pursuant to N.J.S.A. 39:6A-3.1, 39:6A-4 or the emergency personal injury protection coverage provided by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c. 89.
"PIP dispute" includes, but is not limited to, matters concerning:
1. Interpretation of the insurance contract's PIP provisions;
2. Whether the medical treatment or diagnostic tests are in accordance with the provisions of applicable statutes and rules for the basic and standard policies and in compliance with the terms of the policy;
3. Eligibility of the treatment or service for compensation or reimbursement, including whether the injury is causally related to the accident and the application of deductible and copayment provisions;
4. Eligibility of the provider performing the service to be compensated or reimbursed under the terms of the policy and the provisions of N.J.A.C. 11:3-4, and including whether the provider is licensed or certified to perform the treatment or service;
5. Whether the treatment was actually performed;
6. Whether the diagnostic tests performed are recognized by the Professional Boards in the Division of Consumer Affairs, Department of Law and Public Safety, administered in accordance with their standards, and approved by the Commissioner at N.J.A.C. 11:3-4;
7. The necessity and appropriateness of consultation with other health care providers;
8. Disputes involving the application of, or adherence to, the automobile insurance medical fee schedule at N.J.A.C. 11:3-29;
9. Whether the treatment or service is reasonable, necessary and in accordance with medical protocols adopted by the Commissioner at N.J.A.C. 11:3-4; or
10. Amounts claimed for PIP income continuation benefits, essential services benefits, death benefits and funeral expense benefits.
"Provider" or "health care provider" is as defined at N.J.A.C. 11:3-4.2.
"Standard policy" means an automobile insurance policy including PIP coverage as provided in N.J.S.A. 39:6A-4.
"UCJF" means the Unsatisfied Claim and Judgement Fund created pursuant to N.J.S.A. 39:6-61 et seq.