The “New York Comprehensive Auto Insurance Act,” which most people call the “no-fault statute,” was enacted in 1973 and went into effect the following year. The purpose of the law was to limit the number of personal injury claims for car accidents, as many politicians had this agenda on their platforms.
The no-fault statute was innovative in that it provided for immediate payment for medical care, loss of income, and other reasonable out-of-pocket expenses incurred as a result of injuries from a car accident. The law states that these expenses must be paid up to $ 50,000 per person. These payments are what is known as “own benefits” or “basic economic loss”. The reason it is called no-fault is that these payments are made no-fault. If you lose control of your car and hit a tree, you still receive these payments.
If your medical bills, lost income, and / or out-of-pocket costs total more than $ 50,000, you can still sue the party who caused your injuries for these additional amounts (as well as pain and suffering). Due to the negligence of another, you can still initiate an action. No-fault does not cover property damage, so you should still sue for damage to your car unless you have “collision” or “full coverage” for your vehicle.
WHO IS COVERED?
“No-fault benefits are provided for economic losses arising from the use or operation of a motor vehicle (Section 5103 of the Insurance Act). Section 5102 defines a motor vehicle as” all vehicles on a public highway accept motorcycles. “. Motorcycles were intentionally excluded due to the frequency of accidents, which would have made motorcycle insurance too expensive.
You are covered by no-fault insurance, and therefore what the statute calls a “covered person,” whether you are the policy holder, a driver or passenger in the vehicle, or a pedestrian injured by the operation of the vehicle. If you are not the policy holder and the auto insurance is not current, you would be covered by “first-party” no-fault benefits under any auto insurance policy on your home. For example, if your adult child in your household had a car, it would cover you. If there is no “domestic car,” there is a state fund called the “Motor Vehicle Accident Compensation Corporation” (MVAIC) that would provide “no-fault” benefits.
There are some exclusions that you should be aware of. First of all, there must be an accident. No-fault benefits will not be paid if an injury is caused by an intentional act. Most insurance policies deny willful acts, no fault, and other types of claims. For example, you wouldn’t expect your homeowners insurance to pay for damage caused because you didn’t like your carpet anymore, so you put ink on it. Likewise, if someone intentionally crashes into your car, insurance will not cover the loss. Fortunately, this kind of thing doesn’t happen very often!
You are also not covered if you are “in the course of your employment.” This applies, for example, if you drive a taxi, work as an ambulance attendant, or are on a sales call. In most cases, workers’ compensation will pay somewhat similar benefits that will be covered in another article.
If you are the driver and are driving under the influence of alcohol, the no-fault benefits will not be paid for you, but will be paid for the passengers or pedestrians you have injured. Not surprisingly, if you are injured while committing a crime or trying to avoid law enforcement, no benefits will be paid. Coverage will also not be provided if you are operating a vehicle that is known to have been stolen.
So the positive side of “no fault” is that you are automatically entitled to payment for medical expenses and many other things if you are involved in a car accident, except for the exclusions mentioned above. The downside is that to have a negligent “tort” claim against the operator who caused your injuries, you must have what the law defines as a “serious injury.” I will explain this in more detail later in this article.
WHAT DO YOU GET IF YOU ARE COVERED?
Section 5102 of the Insurance Act defines it as $ 50,000 per person for:
All necessary expenses incurred for medical and related services, therapy, certain non-medical treatment by an accepted religious method, and other professional health services, provided that their occurrence can be determined within one year of the injury;
Loss of income and reasonable and necessary expenses incurred to obtain services instead of those that such persons would have incurred to obtain income, up to $ 2,000 per month for up to three years;
All other reasonable and necessary expenses incurred up to $ 25 per day for no more than one year after the accident.
The first paragraph describes the types of medical treatment that are covered. Non-medical treatments may include acupuncture and some other holistic therapies, but I would not risk pushing for “religious” treatments that are not widely recognized. The benefits paid are on a “fee schedule” and the treating medical professionals cannot charge a higher fee, making it a challenge to find doctors willing to accept no-fault payments. Most chiropractors and physical therapists accept it, but it can be difficult to find specialists such as orthopedic doctors, neurologists, and plastic surgeons.
The second paragraph allows the payment for demonstrable lost profits due to an accident. If you are self-employed, you can file your tax returns to show a loss of income. Generally, you must provide three years of tax returns: two prior years showing your usual earnings and the year the accident occurred showing you earned less. If you need to hire someone to temporarily replace you, such as someone to drive your taxi when you own the medallion, you can be reimbursed for the amount you are paying for the replacement driver. Obviously, if you are working “off the books,” you cannot file a claim for lost income benefits.
The third paragraph offers a small amount of money that is generally used to reimburse taxis for medical treatment and similar costs. You can also be reimbursed for household help if you are unable to care for your children or take care of your home (but only $ 25 per day). There is the option to purchase an additional $ 25,000 after the $ 50,000 is depleted, but very few people choose to purchase this additional coverage. Your no-fault insurance benefits will, in some circumstances, even cover you for accidents that occur in other states.
CALENDAR
A no-fault application must be made to the insurance company within thirty days of the accident. All claims must be submitted within 180 days of the date of service. Most insurance companies will pay benefits promptly. Issues related to the adequacy of the proof provided may arise, which may delay payment. Insurance companies sometimes claim that the treatment is not medically necessary and deny payment, in which case the doctor can arbitrate this denial or sue the insurance company for payment of your bills. It is worth dealing with medical professionals who are willing to conduct these arbitrations, rather than end up being liable for payment, or with a link to your case, in case the insurance company refuses to pay. The insurance company also has the right to be seen by the doctors they hire to determine if your treatment is necessary. Over time, as your injuries improve, the insurance company-contracted physician will “deny” your medical treatment because it is no longer needed, which may also be arbitrated or litigated by your treating medical professional.
HOW DOES THE NEW YORK LAW DEFINE “SERIOUS INJURY”?
The threshold for “serious injury” is defined in §5102 (d). Damages for pain and suffering are recoverable only if the claimant sustains injuries that result in:
Death; gold
Dismemberment; gold
Fracture; gold
Significantly disfigured; gold
Loss of a fetus; gold
Permanent loss of use of an organ, limb, function or system of the body; gold
Permanent consequential limitation of the use of a bodily function or system; gold
Significant limitation of the use of a body function or system; gold
Medically determined injury or impairment of a non-permanent nature, which prevents the injured person from performing substantially all the material, acts that constitute the usual or habitual activities of said person for no less than 90 days during the 180 days immediately after the occurrence or injury .
The first two categories above are obvious. Fractures show up on X-rays and will always reach the threshold for serious injury, no matter how small. A small fracture of the left little finger will suffice, even if treatment is not required and there is no disability. Significant disfigurement is less clear. Usually the problem is cuts and abrasions on the face or other visible parts of the body that result in “scars” and whether or not the remaining marks are truly disfiguring. Jurisprudence explains that the scar must be so unattractive that the person is the object of “pity and contempt.” A brand that has to be “flagged” will not reach the threshold.
With the loss of a fetus, it must be shown that the miscarriage was actually caused by the accident. It would not be credible to claim that a miscarriage was caused by a minor impact, especially if the woman did not immediately seek medical treatment for the injuries and lost the baby a month later.
The “permanent loss” and “significant limitation” sections were intended to cover paralysis or other serious loss of use, but have grown to include much less serious deficiencies such as ligament tears and hernias of the neck and back. There should always be objective evidence such as MRI and doctor’s report to support these claims, subjective pain claims are never enough to reach the threshold for serious injury.
The threshold is reached when an injured person loses more than 90 days of work due to their injuries. Time away from work doesn’t have to be immediate and it doesn’t have to be consecutive. For example, a person might be out of work for a month after an accident, try to go back to work, go out again, come back, have surgery, and then go out again to recover. As long as you add more than 90 days out of the first 180 days, you meet the serious injury threshold as long as a doctor certifies that you were, in fact, unable to work. It is not impossible, but it is much more difficult to qualify under this aspect without a full-time paid job, but there are some circumstances in which it could apply. For example, a housewife with young children might not be able to provide care and need to hire childcare services for her children, losing 90 out of 180 of her usual activities.