No-Fault Arbitration Services

It is the simplified arbitration that Insurance Law 5106(b) requires every no-fault insurer to offer for disputes over first-party benefits. It is an option, not a requirement: a provider may bring a court action instead. Requests are filed with the American Arbitration Association, the organization the Department of Financial Services designates, and go through conciliation before an arbitrator decides them.

The regulation sets the steps: conciliation for up to 60 days; the insurer’s 30 days, extendable by 30, to submit its documents; a hearing, or a decision on papers for some disputes under $2,000; and an award within 30 days of the hearing or the final submissions. 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 forum’s calendar decides the rest.

The arbitrator decides on the documents both sides submitted and any testimony, given under oath. The written record closes when the insurer’s submission arrives or its time runs out; later papers are marked late unless the arbitrator asks for them. A stenographic record is optional and paid for by the party that wants it. The award must state the issues, findings and conclusions, and decide every issue submitted (11 NYCRR 65-4.2(b)(3), 65-4.5).

Yes, if a valid claim was overdue or denied when you filed. The award directs the insurer to pay a fee within 11 NYCRR 65-4.6: generally 20% of the benefits plus interest, capped at $1,360 per applicant per arbitration; policy-issue disputes are paid hourly under separate limits. A higher fee needs a novel or unique issue. Where charges exceed the fee schedule, no insurer-paid fee is due unless the dispute is the schedule’s interpretation or an inadvertent error.

The rules generally require all supporting documents with the request; later the applicant may add bills for ongoing benefits, and other papers only at the arbitrator’s request or with approval (11 NYCRR 65-4.2(b)(3)). That means the bills with proof of mailing dates, the assignment, verification requests and your replies, the denial forms, treatment records and reports supporting medical necessity, and anything answering the insurer’s examination or peer review. Ask the insurer in writing for the report behind a medical denial (65-3.8(b)(4)).

Defenses insurers raise include late proof of claim beyond 45 days, lack of medical necessity based on an examination or peer review, unanswered verification or a missed EUO, charges above the fee schedule, coverage or policy issues, and provider eligibility such as licensing. Each calls for its own proof: mailing and verification dates, the medical record, the fee-schedule calculation, the licence. A policy-issue defense also changes how the attorney’s fee is calculated (65-4.6(c)).

Yes, within short limits. Either party may ask a master arbitrator to vacate or modify an award within 21 calendar days of its mailing ($75 for an applicant). The grounds are narrow: article 75 grounds other than failure to follow article 75 procedure, awards above policy limits, an award incorrect as a matter of law, or fee-limit errors. After the master award, a party can seek article 75 review or, only if the master award is $5,000 or more excluding interest and fees, start a new court action.

The American Arbitration Association, as the organization designated by the Department of Financial Services; all optional no-fault arbitrations are administered by it (11 NYCRR 65-4.2(a)(3)). DFS directs that requests be filed with the AAA on Form AR1 or online through the New York Insurance ADR Center, or mailed to its New York Insurance Case Management Center at 32 Old Slip. Master arbitrators are New York attorneys appointed by the Superintendent (65-4.10(b)).

The applicant’s filing fee is $40, returned by the insurer if you prevail in whole or in part; a master arbitration request costs an applicant $75, also reimbursed if you prevail. Each party gets one adjournment without a fee if requested at least two business days ahead; later adjournments cost $50, or $100 within two business days of the hearing. Your own arrangement with counsel is separate; an insurer-paid fee, if awarded, is capped and may not cover all legal costs.

The regulation allows either: a party may represent itself or be represented by an attorney (11 NYCRR 65-4.5(k)). The practical issue is the file. Supporting documents generally go in with the request, and after an award a master arbitration request is due within 21 days of its mailing; applications to vacate or modify under article 75 have 90 days from a master award’s delivery. If the bills were overdue or denied, the insurer pays a capped attorney’s fee when you prevail.