Can You Reopen a No-Fault Claim?

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 remain “open” unless fully paid out or denied. No-fault claims which are denied may be reopened under certain circumstances.

You can reopen a No-Fault denial through arbitration or court litigation, but this should not be done by either you or your personal injury lawyer before your personal injury lawsuit is settled. This is because a decision declining reopen a No-Fault denial can be used against you in your personal injury lawsuit.

Status of a No-Fault Claim — Open or Closed?

  • Open
  • Closed (a fraudulent term)
  • Denied (as to one or more benefits) -Failure to timely apply or comply
  • Paid out / exhausted

Your No-Fault Claim Is Open

As it implies, your No-Fault file is open and available with all benefits.

Your No-Fault Claim Is Closed

Can a No-Fault claim be closed? No. A common ruse by insurance companies is to say that your No-Fault file is closed when you have not been denied No-Fault benefits! This is really done with fraudulent intent.

The reason this is fraudulent is that insurance claim reps tell doctors your No-Fault file or claim is closed to make them think you are no longer entitled to benefits.

How Does an Insurance Company Close a No-Fault File?

Insurance companies “close” your file in the computer when medical bills have not been submitted within a certain time, such as 60 days. The correct term is called archiving.

So the No-Fault claim representative doesn’t have to look at too many inactive files on the computer; inactive files are simply archived or moved to another folder on the computer. The No-Fault claim representative simply has to click a button to unarchive the file. We have the same thing in our personal injury software for clients.

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 Reopen a Closed No-Fault File

Simply submit a new bill for medical services, and your No-Fault file will be reopened. You can probably even send in a previously paid or denied medical bill!

Your No-Fault Claim Is Denied

Your no-fault claim can be denied for various reasons.

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 “Independent” Medical Examination (IME) requested by your no-fault insurance company.
  • You appeared at a No-Fault “Independent” Medical Examination, but the No-Fault doctor said you no longer need medical treatment.
  • Treatment for a particular injury is denied because you did not notify the insurance company of that injury within the time allowed.
  • Payment for medical treatment may be denied if the treatment is determined to be unrelated to your accident; 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, if you did not notify the No-Fault insurance company of a dental injury within 12 months of the accident and you go to see a dentist after 12 months, you will be denied No-Fault benefits for your dental injury.

Your No-Fault insurance company will send you for a physical exam by a No-Fault 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 a No-Fault doctor 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 denied medical treatment.

You are entitled to have someone accompany you to the No-Fault IME to protect you. Ask your lawyer to have someone accompany you to your No-Fault IME. Don’t go alone to an IME.

Can You Reopen a No-Fault Claim 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, which denied treatment and now allows further treatment, the No-Fault insurance company must reopen your claim. We have been successful in doing this with several cases.