Detailed Answer
If an insurance adjuster in New York denies that your medical treatment relates to a car accident, follow these steps to protect your rights and secure proper payment under New York’s no-fault insurance law.
1. Understand New York’s No-Fault Benefits
Under New York Insurance Law §5102, every auto policy must cover “basic economic loss” (PIP), including all “reasonable and necessary” medical expenses. An adjuster cannot arbitrarily deny treatment if it meets these criteria. (NY Ins. Law §5102)
2. Review the Denial Letter
By law, the insurer must send a written denial within 30 days of receiving your claim or proof of treatment. That letter must cite specific reasons for the denial, such as lack of causation or unreasonable charges. (NY Ins. Law §5104)
3. Gather Supporting Evidence
- Obtain detailed medical records and billing statements.
- Ask your treating physician to prepare a letter explaining how each service relates to the accident.
- Collect diagnostic reports (X-rays, MRIs) showing accident-related injuries.
4. Send a Demand Letter
Prepare a written demand to the insurer, attaching all evidence. State that the treatment is “reasonable, necessary, and causally related” under §5102. Highlight any errors in the adjuster’s denial letter. Send by certified mail and keep proof of delivery.
5. Request Examination or Independent Medical Review
If the insurer requests a physical exam, cooperate but insist on a neutral examiner when possible. If you suspect bias, request an independent medical review through New York’s arbitration process.
6. File for No-Fault Arbitration
If the insurer still refuses payment within 30 days of your demand, you can file for arbitration under New York Insurance Law §5104. Arbitration is faster and less formal than court. You can initiate it through the New York State Department of Financial Services (DFS) or your local county clerk.
7. Consider a Lawsuit
If arbitration does not resolve the dispute, or if you exceed arbitration limits, you may file a lawsuit in New York Supreme Court. Consult an attorney experienced in no-fault cases to review deadlines and procedures.
8. Report Unfair Practices
If you believe the insurer acted in bad faith or violated New York Insurance Regulation (11 NYCRR Part 60), file a complaint with the New York State Department of Financial Services: DFS Consumer Complaint.
Disclaimer: This article is for educational purposes only. It does not constitute legal advice. Consult a licensed attorney to address your specific situation.
Helpful Hints
- Act quickly to preserve your right to no-fault benefits.
- Keep organized records of all medical visits and communications.
- Use clear, concise language in your demand letter.
- Know that you have a statutory right to arbitration if the insurer denies your claim.
- File complaints with DFS to put regulatory pressure on the insurer.
- Consult an attorney if you face ongoing disputes or complex injuries.