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 65-3.5 - Claim procedure

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Within
					 10 business days after receipt of the completed application for motor vehicle
					 no- fault benefits (NYS form NF-2) or other substantially equivalent written
					 notice, the insurer shall forward, to the parties required to complete them,
					 those prescribed verification forms it will require prior to payment of the
					 initial claim.
(b) Subsequent to
					 the receipt of one or more of the completed verification forms, any additional
					 verification required by the insurer to establish proof of claim shall be
					 requested within 15 business days of receipt of the prescribed verification
					 forms. Any requests by an insurer for additional verification need not be made
					 on any prescribed or particular form. If a claim is received by an insurer at
					 an address other than the proper claims processing office, the 15 business day
					 period for requesting additional verification shall commence on the date the
					 claim is received at the proper claims processing office. In such event, the
					 date deemed to constitute receipt of claim at the proper claim processing
					 office shall not exceed 10 business days after receipt at the incorrect
					 office.
(c) The insurer is entitled
					 to receive all items necessary to verify the claim directly from the parties
					 from whom such verification was requested.
(d) If the additional verification required
					 by the insurer is a medical examination, the insurer shall schedule the
					 examination to be held within 30 calendar days from the date of receipt of the
					 prescribed verification forms.
(e)
					 All examinations under oath and medical examinations requested by the insurer
					 shall be held at a place and time reasonably convenient to the applicant and
					 medical examinations shall be conducted in a facility properly equipped for the
					 performance of the medical examination. The insurer shall inform the applicant
					 at the time the examination is scheduled that the applicant will be reimbursed
					 for any loss of earnings and reasonable transportation expenses incurred in
					 complying with the request. When an insurer requires an examination under oath
					 of an applicant to establish proof of claim, such requirement must be based
					 upon the application of objective standards so that there is specific objective
					 justification supporting the use of such examination. Insurer standards shall
					 be available for review by department examiners.
(f) An insurer must accept proof of claim
					 submitted on a form other than a prescribed form if it contains substantially
					 the same information as the prescribed form. An insurer, however, may require
					 the submission of the prescribed application for motor vehicle no-fault
					 benefits, the prescribed verification of treatment by attending physician or
					 other provider of health service, and the prescribed hospital facility
					 form.
(g) In lieu of a prescribed
					 application for motor vehicle no-fault benefits submitted by an applicant and a
					 verification of hospital treatment (NYS form NF-4), an insurer shall accept a
					 completed hospital facility form (NYS form NF-5) (or an NF-5 and uniform
					 billing form [UBF-1] which together supply all the information requested by the
					 NF-5) submitted by a provider of health services with respect to the claim of
					 such provider.
(h) When benefits
					 are claimed under an additional personal injury protection endorsement, the
					 insurer may require that the applicant execute a prescribed subrogation
					 agreement (NYS form NF-11) prior to the payment of any benefits. If the insurer
					 shall impose the above requirement, it shall deliver the prescribed agreement
					 to the applicant as soon as it is known that the claim is payable under an
					 additional personal injury protection endorsement.
(i) If the insurer has knowledge that the
					 applicant for benefits under a mandatory or additional personal injury
					 protection endorsement is entitled to benefits under any other mandatory or
					 optional first-party automobile or no-fault automobile insurance for the same
					 elements of loss, the insurer should give written notice of claim to all other
					 such sources of benefits in order to protect its right under the endorsement to
					 recover from such other sources their proportionate share of the costs of the
					 claim and the allocated expenses of processing the claim.
(j) Every insurer who does not staff and
					 maintain a claims office in this State shall establish a communications system,
					 by means of a direct toll-free telephone line, to conveniently process all
					 claims made pursuant to article 51 of the Insurance Law. Such toll-free number
					 shall appear on all correspondence relating to claims.
(k) Every insurer, which writes more than
					 1,000 motor vehicle liability policies in this State, shall establish
					 procedures for the receipt of all claims, notices and verification, subject to
					 this Part, by facsimile and/or electronic data transmittal.
(l) The insurer shall establish standards for
					 review of its determinations that applicants have provided late notice of claim
					 or late proof of claim. In the case of notice of claim, such standards shall
					 include, but not be limited to, appropriate consideration for pedestrians and
					 nonrelated occupants of motor vehicles who may have difficulty ascertaining the
					 identify of the insurer. In the case of proof of claim, such standards shall
					 include, but not be limited to, appropriate consideration for emergency care
					 providers, demonstrated difficulty in ascertaining the identity of the insurer
					 and inadvertent submission to the incorrect insurer. The insurer shall
					 establish procedures, based upon objective criteria, to ensure due
					 consideration of denial of claims based upon late notice or late submission of
					 proof of claim, including supervisory review of all such determinations.
					 Insurer standards shall be available for review by department
					 examiners.
(m) The failure of an
					 employer, or other third party, to provide information necessary to establish
					 proof of claim for lost wages on behalf of an applicant shall not be utilized
					 as a basis for denial of claim based upon late submission of proof of
					 claim.
(n) The timely submission of
					 a proof of claim by a hospital that is based upon Diagnostic Related Group
					 (DRG) codes which may be adjusted prospectively shall be deemed to be timely
					 notice for the submission of a subsequent claim which is adjusted in accordance
					 with the promulgation of DRG codes which were not implemented at the time of
					 the original submission of claim.
(o) An applicant from whom verification is
					 requested shall, within 120 calendar days from the date of the initial request
					 for verification, submit all such verification under the applicant's control or
					 possession or written proof providing reasonable justification for the failure
					 to comply. The insurer shall advise the applicant in the verification request
					 that the insurer may deny the claim if the applicant does not provide within
					 120 calendar days from the date of the initial request either all such
					 verification under the applicant's control or possession or written proof
					 providing reasonable justification for the failure to comply. 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 subdivision 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.
(p) With respect to a verification request
					 and notice, an insurer's non-substantive technical or immaterial defect or
					 omission, as well as an insurer's failure to comply with a prescribed time
					 frame, shall not negate an applicant's obligation to comply with the request or
					 notice. 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.