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Exclusions from No-Fault Coverage

With the increased rejection of billing by commercial insurers and government payers for treatment perceived to be related in whole or in part to an auto accident, we are providing a brief overview of what is not covered by No-Fault insurance. Specifically, the No-Fault insurer is not obligated to pay for treatment rendered to persons who have sustained injuries resulting from the following:

  1. Driving while intoxicated or impaired by use of a drug that contributes to the accident, except for emergency health related services performed in a general hospital or by an ambulance worker outside of a general hospital.[1][2]
  1. Caveat 1: The No-Fault insurer is precluded from raising intoxication as a defense to payment of a claim if it fails to preserve said defense in a timely denial.[3]
  1. Caveat 2: To assert intoxication as a defense to payment, the No-Fault Insurer must prove two things:
  1. The eligible injured person (“EIP”) was operating his/her vehicle in an intoxicated/impaired condition, and
  1. The EIP was injured due to operating his/her vehicle while in an intoxicated/impaired condition.[4]
  1. Intentionally causing one’s own injuries.[5]
  1. Riding an all-terrain vehicle (ATV) or a motorcycle as operator or passenger (a pedestrian struck by a motorcycle or ATV is covered).[6]
  1. Injured while committing a felony or seeking to avoid lawful apprehension or arrest by a law enforcement officer.[7]
  1. Injured while operated a vehicle in a race or speed test.[8]
  1. Injured while operating or occupying a vehicle known to be stolen.[9]
  1. Injured while repairing, servicing or otherwise maintaining a motor vehicle if the conduct is within the course of a business of repairing, servicing or otherwise maintaining a motor vehicle and the injury occurs on the business premises.[10]
  1. An owner of an uninsured vehicle.[11]

Russell Friedman & Associates is not just a collection practice; we do All Things No Fault®, including consulting and compliance work. If you need help navigating the No Fault billing process or to learn more about pursuing No Fault arbitration and how the Firm can provide quality legal counsel during the process, please contact us today.

[1] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(j)

[2] The No-Fault Insurer has the right to recover from the intoxicated or impaired driver the full amount of those No-Fault payments made by the automobile insurer for the emergency services provided to the driver if the driver is convicted of driving while intoxicated or impaired through the use of alcohol or drugs. See, Insurance Law § 5103(b)(2); The New York State Department of Financial Services (“DFS”) Circular Letter 4, dated January 12, 2011 (“the Circular Letter”), https://www.dfs.ny.gov/insurance/circltr/2011/cl2011_04.htm.

[3] Presbyterian Hosp. in City of N.Y. v. Maryland Cas. Cop., 90 N.Y.2d 274, 286, 660 N.Y.S.2d 536 (1997), Westchester Medical Ctr. V. New York Cent. Mut. Fire Ins. Co., 917 N.Y.S.2d 275, 276, 2011 N.Y. Slip Op. 01458 (2d Dept. 2011).

[4] Cernik v. Sentry Ins., 131 AD2d 952 at 953 (3rd Dept. 1987), Westchester Medical Center v. Progressive Insurance Company, 51 A.D.3d 1014 (2d Dept. 2008), Westchester Medical Center v. Government Employees Insurance Company, 77 A.D.3d 737 (2d Dept. 2010).

[5] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(i)

[6] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(h)

[7] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(k)(1)

[8] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(k)(2)

[9] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(k)(3)

[10] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(k)(4)

[11] N.Y. Comp. Codes R. & Regs. tit. 11, § 65-2.3(a)

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