Health Care Litigation for No-Fault Providers

No-fault benefits pay necessary health expenses of people hurt in motor vehicle accidents, within the policy's limits. With a properly executed assignment, the insurer pays the provider directly (11 NYCRR 65-3.11). Charges are generally limited to the fee schedules unless unusual procedures or unique circumstances justify more, and a provider may not ask for payment beyond the authorized charges (Insurance Law 5108). Proof of claim is due within 45 days after the service; the insurer then has verification steps and a 30-day pay-or-deny rule.

A denial form can cite late proof of claim (after 45 days without a reasonable justification), lack of medical necessity based on an independent medical examination or a peer review, unanswered verification or a missed examination under oath, charges above the fee schedule, a coverage question, or provider eligibility such as licensing. Whether the ground holds depends on the dates and records. You can ask in writing for a copy of the examination or peer review report the denial relies on (65-3.8(b)(4)).

The 30 calendar days run from when the insurer has proof of claim, including any verification it properly requested; an examination counts as received on the day it is held. If the insurer neither pays nor denies in that time, the benefits are overdue. They carry interest at 2% per month, figured pro rata on a 30-day month, and an attorney’s fee within the state’s limits (Insurance Law 5106(a); 11 NYCRR 65-3.8, 65-3.9). Overdue does not mean every defense is lost.

An examination under oath is sworn questioning an insurer may request as verification before it pays. The request must rest on objective standards and be held at a reasonably convenient place and time (11 NYCRR 65-3.5(e)). Missing a properly requested EUO can lead to a denial, so respond in writing and in time. Whether a particular request was proper depends on how and when it was made. Our managing no-fault attorney attends EUOs with providers; see our EUO page.

Yes. Insurance Law 5106(b) makes arbitration an option the insurer must offer, not a requirement. A provider holding an overdue or denied bill can file with the American Arbitration Association or bring a court action. Arbitration costs a $40 filing fee and has short clocks after the award; a court action follows court procedure. Either route can carry interest and a capped attorney’s fee. If you do neither within 30 days of receiving a denial, interest pauses until you do (65-3.9(c)); that is an interest rule, not a filing deadline.

Start with the payment rules: submit proof of claim within 45 days of the service or document why you could not; keep a properly executed assignment for each patient; keep charges within the fee schedules unless an exception applies, and do not ask the patient for more than the authorized charges (Insurance Law 5108); keep licences in order (65-3.16(a)(12)); and answer written verification requests within 120 days or explain why not. Our compliance page covers billing reviews.

If a valid claim was overdue or denied, the insurer pays your attorney’s fee, within limits set by regulation. In arbitration or court it is generally 20% of the benefits plus interest, capped at $1,360 per applicant per proceeding; policy-issue disputes have hourly limits; more requires a novel or unique issue (11 NYCRR 65-4.6). Charges over the fee schedule generally bar an insurer-paid fee, except in schedule-interpretation or inadvertent-error disputes. Your own arrangement with counsel is separate.

The bill (NF-3, NF-4 or NF-5) with proof of the date you mailed or sent it; the signed assignment; treatment records supporting each service; every verification request with your dated response; EUO and examination notices, transcripts and reports; denial forms with the dates you received them; and the payment history. In arbitration the rules generally require all supporting documents with the request, so the file should be complete before filing (11 NYCRR 65-4.2(b)(3)).

File with the American Arbitration Association, with a $40 fee. Conciliation can last up to 60 days; the insurer then has 30 days to submit its documents. If you file within 90 days after the bill became overdue or was denied, you can ask for a hearing within 45 days of transmittal. The award is due within 30 days after the hearing ends or final papers reach the arbitrator. A master arbitration request is due within 21 days of the award’s mailing; otherwise the insurer pays within 30 days.