Detailed Answer
North Carolina’s Rule 414 governs how medical bills may be reduced under North Carolina’s civil procedure rules. That rule does not apply in New York. If you’ve been injured in a motor vehicle accident in New York and have no-fault (Personal Injury Protection) coverage, your insurer must follow New York’s Insurance Law and associated regulations when paying medical expenses.
Under New York Insurance Law §5106 (nysenate.gov/legislation/laws/INS/5106), no-fault insurers pay up to a set fee schedule for medical services provided after a covered accident. Insurers may:
- Pay providers at the maximum charge listed in the no-fault fee schedule.
- Refuse to cover bills that exceed the fee schedule without a valid pre-approval or exception.
- Request documentation to verify that billed services relate directly to the covered motor vehicle accident.
If your medical provider’s bill exceeds the maximum allowed charge, the insurer can reduce payment to that maximum. However, the insurer cannot apply North Carolina procedural rules or arbitrary percentage cuts unrelated to New York’s fee schedule.
When a dispute arises over a reduction, you or your provider can challenge the denial or reduction by submitting supporting medical records and letters of medical necessity. If the insurer still refuses, you may file a complaint with the New York State Department of Financial Services (DFS) or seek a declaration from a court that the services were reasonable and necessary.
Disclaimer: This article is for educational purposes only and does not constitute legal advice. Consult a qualified attorney to discuss your specific situation.
Helpful Hints
- Review your no-fault policy to confirm coverage limits and billing rules.
- Obtain an itemized bill and compare it against the official fee schedule.
- Ask your provider to apply for an exception or fee-schedule adjustment if services exceed the maximum charge.
- Document communications with the insurer and save any denials or reduction notices.
- If the insurer reduces payment improperly, file a complaint with DFS (dfs.ny.gov) or consult an attorney experienced in New York no-fault matters.