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 65-3.13 - Sources of additional personal injury protection benefits

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Institution of
					 claims-priority. Generally, an applicant's initial source of additional
					 personal injury protection benefits will be the same source which provides the
					 mandatory personal injury protection benefits, until the total available limits
					 under that source's mandatory and additional personal injury protection
					 coverages are exhausted. Specifically:
(1) An
					 applicant who is an operator or occupant of an insured motor vehicle covered
					 for additional personal injury protection benefits, and 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 a
					 named insured or a relative of a named insured covered by additional personal
					 injury protection benefits, and who, while an operator or occupant of a motor
					 vehicle, sustains a personal injury arising out of the use or operation of such
					 motor vehicle outside of New York State, shall institute the claim against the
					 insurer of the named insured or the relative. Where there is more than one
					 insurer which would be the source of benefits, the first such insurer applied
					 to shall process the claim, unless the insurers agree among themselves that
					 another such insurer will accept and pay the claim initially. (See subdivision
					 [b] of this section.) If the insurers do not reach an agreement, then each
					 insurer that concludes 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.
(3) An
					 applicant who is a named insured or a relative of a named insured covered for
					 additional personal injury protection benefits, and who is neither an operator
					 nor an occupant of a motor vehicle or a motorcycle, and who sustains a personal
					 injury through the use or operation of a motor vehicle or a motorcycle shall
					 institute the claim against the insurer of the named insured or the relative.
					 Where there is more than one insurer which would be the source of benefits, the
					 first such insurer applied to shall process the claim, unless the insurers
					 agree among themselves that another such insurer will accept and pay the claim
					 initially. (See subdivision [b] of this section.) If the insurers do not reach
					 an agreement, then each insurer that concludes 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.
(4) An
					 applicant who is not a named insured or a relative of a named insured covered
					 for additional personal injury protection benefits, and who is an occupant of
					 an insured motor vehicle covered for additional personal injury protection
					 benefits or a motor vehicle operated by a person covered for additional
					 personal injury protection benefits, and who sustains a personal injury through
					 the use or operation of the insured motor vehicle outside of New York State,
					 shall institute the claim against the insurer of the owner or operator of the
					 insured motor vehicle. Where there is more than one insurer which would be the
					 source of benefits, the first such insurer applied to shall process the claim
					 unless the insurers agree among themselves that another such insurer will
					 accept and pay the claim initially. (See subdivision [b] of this section.) If
					 the insurers do not reach an agreement, then each insurer that concludes 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.
(5) An
					 applicant who has exhausted the additional personal injury protection benefits
					 available under the initial sources as set forth in this section, shall then
					 apply for benefits from the next available source providing a higher level of
					 additional personal injury protection benefits. This latter source shall
					 provide benefits to the extent that the total limit available under such latter
					 source exceeds the amount available under the initial sources as set forth in
					 this section. This process will repeat until all available additional personal
					 injury protection benefit sources have been exhausted.
(6) If a dispute arises among insurers who
					 are liable for the payment of additional personal injury protection 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 additional personal injury protection 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 additional personal injury protection
						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.