New York No-Fault Insurance: The 30-Day Claim Deadline and What PIP Actually Covers

If you were hurt in a car accident in New York, the first insurance claim you file will almost always be a no-fault claim. New York's no-fault system, set out in Article 51 of the Insurance Law (§§ 5101 through 5109) and Regulation 68 (11 NYCRR Part 65), pays your medical bills and part of your lost wages regardless of who caused the crash. It also imposes a short filing deadline that trips up thousands of injured people every year. This page explains that deadline, what Personal Injury Protection (PIP) pays for, what it excludes, and what to do when a carrier delays or denies benefits.

The 30-Day Written Notice Requirement

The mandatory PIP endorsement prescribed by 11 NYCRR 65-1.1 requires that written notice of the accident be given to the insurer "as soon as reasonably practicable, but in no event more than 30 days after the date of the accident." The notice must include the time, place, and circumstances of the accident, the name and address of each injured person, and the name and address of any available witnesses. In practice, you satisfy this by filing the New York State Application for Motor Vehicle No-Fault Benefits, known as Form NF-2, with the correct insurer.

Two points about this deadline deserve emphasis. First, it runs from the date of the accident, not from the date you first saw a doctor or first realized you were hurt. Second, it is measured in calendar days. Weekends and holidays count.

A Worked Example

Suppose you are rear-ended on Queens Boulevard on the evening of March 3. You feel stiff but decline an ambulance. On March 20 your neck pain is bad enough that you see an orthopedist. Your 30-day window closed on April 2. If the NF-2 arrives at the insurer on April 5, the carrier can deny every bill connected to the accident unless you show a reasonable justification for the delay.

Late Notice Can Be Excused, But Only If You Ask

The endorsement provides that the 30-day period may be extended if the claimant submits written proof providing "clear and reasonable justification" for the failure to comply. Under 11 NYCRR 65-3.3(e), when an insurer denies a claim for late notice, its denial must advise the claimant that late notice will be excused where the claimant can provide reasonable justification. Carriers comply with this requirement by printing the language on the denial form, and many claimants never read it. If you receive a late-notice denial, respond in writing with the specific facts that caused the delay: a hospitalization, a head injury that impaired your memory, a good-faith belief that the other driver's insurer was handling the claim, or difficulty identifying the correct carrier. The insurer must consider that justification before the denial stands.

Which Insurer Do You File With?

Getting the deadline right does no good if the form goes to the wrong company. Under Insurance Law § 5103 and the priority rules in 11 NYCRR 65-3.12, the responsible insurer is generally:

• Driver or passenger: the insurer of the vehicle you were in, even if the other driver was entirely at fault.
• Pedestrian or cyclist: the insurer of the vehicle that struck you. If that vehicle is uninsured or cannot be identified, you may have a claim under your own household policy or through the Motor Vehicle Accident Indemnification Corporation (MVAIC), which has its own notice requirements under Insurance Law § 5208.
• Occupant of a bus or taxi: the insurer of that commercial vehicle, subject to the special rules for buses in § 5103(a)(1).

Fault does not enter into this analysis. Because no-fault benefits flow from the policy on the vehicle you occupied, the question of who caused the crash is irrelevant to PIP. Comparative fault matters only when you later sue for pain and suffering, a topic covered on our page about being partially at fault in a New York accident.

What PIP Actually Pays: Basic Economic Loss

Insurance Law § 5102(a) defines "basic economic loss" as up to $50,000 per person for the following categories of expense. Section 5102(b) then defines "first party benefits" as basic economic loss minus certain offsets. The categories are:

1. Medical and Related Expenses

All necessary expenses for medical, hospital, surgical, nursing, dental, ambulance, X-ray, prescription drug, and prosthetic services, plus psychiatric, physical, and occupational therapy and rehabilitation. Non-medical remedial care rendered in accordance with a recognized religious method of healing is also included. There is no separate sub-limit for medical expenses; they draw against the single $50,000 pool. Providers are paid according to the fee schedules adopted under Insurance Law § 5108, which incorporate the Workers' Compensation Board schedules. A provider who accepts no-fault assignment cannot balance-bill you for the difference between its usual charge and the schedule amount.

2. Lost Earnings

Section 5102(a)(2) covers loss of earnings from work you would have performed had you not been injured, and reasonable expenses for substitute services (for example, hiring someone to perform work you did for your own household), capped at $2,000 per month for up to three years from the accident. Section 5102(b)(1) then reduces the benefit by 20 percent of lost earnings. The result is that PIP pays 80 percent of your gross lost wages, up to the $2,000 monthly cap.

Example: you earn $3,000 per month and are out of work for two months on your doctor's orders. Eighty percent of $3,000 is $2,400, which exceeds the cap, so PIP pays $2,000 per month, or $4,000 total. If instead you earn $1,800 per month, PIP pays $1,440 per month. Any New York State disability benefits or workers' compensation benefits you receive for the same period are deducted under § 5102(b)(2).

3. Other Reasonable and Necessary Expenses

Section 5102(a)(3) allows up to $25 per day for up to one year for other reasonable and necessary expenses caused by the injury. This is the provision that reimburses transportation to medical appointments, household help, and similar out-of-pocket costs. Keep receipts. Carriers rarely pay this category without documentation.

4. Death Benefit

Section 5103(a)(2) requires a $2,000 death benefit, payable to the estate of a covered person who dies as a result of the accident, in addition to the $50,000 basic economic loss limit.

Optional Coverage Above $50,000

Policyholders may purchase Optional Basic Economic Loss (OBEL) coverage of an additional $25,000 under § 5102(a)(5) and 11 NYCRR 65-1.2, and Additional PIP (APIP) coverage in higher amounts. If your medical bills are approaching $50,000, ask the carrier in writing whether OBEL or APIP is on the policy. Once basic benefits are exhausted, the claimant elects how OBEL is applied, and the carrier must send you an election form.

Ongoing Proof-of-Claim Deadlines

Filing the NF-2 on time is only the first deadline. The endorsement in 11 NYCRR 65-1.1 imposes two more:

• Medical bills: written proof of claim for health service expenses must be submitted no later than 45 days after the date services are rendered. A physical therapy session on June 10 must be billed to the carrier by July 25.
• Lost wages: written proof of claim for work loss must be submitted within 90 days after the work loss is incurred. Employers verify wages on Form NF-6, and treating physicians confirm disability on Form NF-3 or NF-4.

Most medical providers take an assignment of benefits and bill the carrier directly, so the 45-day deadline is usually their problem rather than yours. Lost wage claims are different. You must obtain and submit the employer verification yourself or through counsel, and missed 90-day windows are a common reason wage claims are denied.

What the Insurer Must Do, and When

Regulation 68 imposes strict timelines on carriers too. Under 11 NYCRR 65-3.5, an insurer that needs more information must request verification within 15 business days of receiving the NF-2 or a bill. Under 11 NYCRR 65-3.8(a), the insurer must pay or deny a claim within 30 calendar days after receiving proof of claim. If the carrier fails to deny within 30 days and has not properly tolled the period with a timely verification request, it is generally precluded from raising most defenses later, including lack of medical necessity. Overdue benefits accrue interest at 2 percent per month under § 5106(a) and 11 NYCRR 65-3.9, and a claimant who prevails in arbitration or litigation is entitled to attorney's fees under 11 NYCRR 65-4.6.

Who Is Excluded From No-Fault

Insurance Law § 5103(b) permits insurers to exclude payment to a person who:

• was injured while operating a vehicle in an intoxicated condition or while impaired by drugs, if that condition was a contributing cause;
• intentionally caused his or her own injury;
• was injured while committing a felony or seeking to avoid lawful apprehension;
• was injured while operating or occupying a motorcycle (motorcycle operators and passengers are not "covered persons" for PIP purposes, though pedestrians struck by a motorcycle are);
• was injured while knowingly operating or occupying a stolen vehicle; or
• owns an uninsured vehicle that was involved in the accident.

Injuries covered by workers' compensation are also carved out. If you were driving for your job, your workers' compensation carrier pays first, and no-fault becomes secondary.

Independent Medical Examinations and Cut-Off Letters

The most frequent no-fault dispute is not the initial filing but the mid-treatment cut-off. Carriers schedule independent medical examinations (IMEs) under 11 NYCRR 65-1.1 and, based on the examiner's report, issue a denial stating that further treatment is not medically necessary. You must attend properly scheduled IMEs; failure to appear at two scheduled examinations is a policy condition violation that can void coverage retroactively. But an IME cut-off is not the end. Your treating physician's records, a rebuttal report, and the carrier's own procedural failures (an untimely IME notice, an examiner outside the relevant specialty, or a denial mailed late) are all grounds to challenge the denial. For a broader discussion of the tactics carriers use, see our page on what to do when an insurance company denies an injury claim.

How No-Fault Disputes Are Resolved

Insurance Law § 5106(b) gives the claimant the option to submit any dispute over first-party benefits to arbitration administered by the American Arbitration Association, or to bring an action in court. Arbitration is faster and is the usual forum for disputed medical bills. Court is sometimes preferable for large lost-wage claims or where preclusion issues make a summary judgment motion likely to succeed. Either way, the carrier bears the burden of proving a timely denial, and a claimant who wins recovers interest and fees in addition to the benefits owed.

No-Fault Is Not Your Whole Case

PIP compensates economic loss only. It pays nothing for pain and suffering. To recover those damages you must sue the at-fault driver, and under Insurance Law § 5104(a) you may do so only if you sustained a "serious injury" as defined in § 5102(d): death, dismemberment, significant disfigurement, a fracture, loss of a fetus, permanent loss of use of a body organ or member, permanent consequential limitation, significant limitation of use of a body function or system, or a medically determined injury that prevented you from performing substantially all of your usual daily activities for at least 90 of the 180 days following the accident. The no-fault file you build in the first months, including the treatment records and disability documentation, becomes the evidence that clears that threshold. That is one reason handling the PIP claim carefully from day one matters. Our insurance claim attorneys manage both tracks so the no-fault record supports the injury lawsuit rather than undermining it.

You can contact the Law Offices of Albert Goodwin by phone at 212-233-1233 or by email at [email protected].