First, what is a no-fault claim? No-fault is insurance that provides several different benefits including payment for medical treatment, medical devices, drugs, household help, and lost income.
You can have a no-fault claim when an injury is caused by the use of a car. There are many case decisions concerning exactly what the use of a car is. For instance, you may have a no-fault claim when you are injured while you are entering or exiting a parked car.
No-fault claims in NY and probably the other no-fault states cannot be settled and thus, always remains “open” unless fully paid out or denied. No-fault claims which are denied may be opened again under certain circumstances. The no-fault insurance company will usually deny further benefits after a period of time, but this is a unilateral denial which can be reopened through arbitration or court litigation.
Following are the statuses of a no-fault claim:
- Closed (a fraudulent term)
- Denied (as to one or more benefits) -Failure to timely apply or comply
- Paid out / exhausted
Open — As it implies, your no-fault file is open and available with all benefits.
Closed — Is your No-Fault file closed? A common ruse by insurance companies is to say that your no-fault file is closed when it is not! This is really done with fraudulent intent.
What the insurance companies are doing is to “close” your file when when medical bills have not been submitted within a certain time such as 60 days.
When your doctor’s office calls to find out if your no-fault claim is open, the insurance company will say it is closed. Your doctor will then tell you that your file has been closed and you cannot get treatment unless you have another way of paying for it.
How to open your no-fault file when it has been closed? Simply submit a new bill for medical services.
Denied — Your no-fault claim can be denied for various reasons.
The most common reasons your no-fault claim may have been denied:
- You failed to submit a no-fault application within the number of days allowed
- You failed to appear at an examination under oath if requested
- You failed to appear at a no-fault medical examination requested by your no-fault insurance company
- You appeared at a no-fault medical examination but their doctor said you no longer need medical treatment; and
- Various other reasons.
No-Fault benefits may also be denied because you did not notify the no-fault insurance company of a particular injury within the time allowed. For instance, in New York, you did not notify the no-fault insurance company of your dental injury within 12 months of the accident and 18 months later you go to see a dentist.
Your no-fault insurance company will send you for a physical exam by a doctor in the same specialty as you are being treated. For instance, if you are seeing a chiropractor, a neurologist, an acupuncturist and a dentist, you will likely be seen by someone in each of those fields who is examining you for the insurance company. This is because you cannot be denied benefits for dental treatment because an orthopedic surgeon said so.
Payment for medical treatment may be denied if the treatment is determined to be unrelated to your accident.
Can your no-fault claim be reopened after it’s been denied? Yes, if your no-fault claim has been denied and your medical provider was not paid, your medical provider may file a lawsuit or arbitration to recover the money that was not paid. If your medical provider wins, your no-fault denial could be reversed.
If the no-fault doctor reverses his or her opinion denying treatment and allows further treatment, the no-fault insurance company must reopen your claim. We have been successful doing this with several cases.