N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-1.3

Current through Register Vol. 46, No. 45, November 2, 2024

Section 65-1.3 - Requirements for additional personal injury protection coverage

(a) The additional personal injury protection endorsement (New York), set out in this section, is approved and promulgated and all of the provisions thereof shall, in accordance with section 2307 (b) of the Insurance Law, be deemed to be included in all additional personal injury protection endorsements in force. This endorsement contains nonsubstantive changes from the previously prescribed additional personal injury protection endorsement (New York) and may be substituted for that endorsement when supplies of that endorsement are exhausted. This endorsement may be combined with the Mandatory Personal Injury Protection Endorsement (New York) and other coverages, with appropriate language.

(b) The endorsement set forth in this section may include the following provision, together with appropriate schedule(s) of named individuals: "It is agreed that the individual(s) named in this endorsement shall be deemed to be a named insured under the Mandatory Personal Injury Protection Endorsement (New York) and, to the extent applicable, this endorsement."

(c) Additional personal injury protection endorsement.

ADDITIONAL PERSONAL INJURY PROTECTION ENDORSEMENT

(New York)

The Company agrees with the named insured subject to all of the provisions, exclusions and conditions of the Mandatory Personal Injury Protection (Endorsement) ¹⁴ (New York), not expressly modified in this (Endorsement) ¹⁴ as follows:

Additional Personal Injury Protection

The Company will pay additional first-party benefits to reimburse for extended economic loss on account of personal injuries sustained by an eligible injured person and caused by an accident arising out of the use or operation of a motor vehicle or motorcycle during the policy period. This coverage only applies to motor vehicle accidents within the United States of America, its territories or possessions, or Canada.¹⁵

Eligible Injured Person

Subject to the exclusions and conditions set forth below, an eligible injured person is:

(a) the named insured and any relative who sustains personal injury arising out of the use or operation of any motor vehicle;

(b) the named insured and any relative who sustains personal injury arising out of the use or operation of any motorcycle while not occupying a motorcycle;

(c) any other person who sustains personal injury arising out of the use or operation of the insured motor vehicle while occupying the insured motor vehicle; or

(d) any other person who sustains personal injury arising out of the use or operation of any other motor vehicle (other than a public or livery conveyance) while occupying such other motor vehicle, if such other motor vehicle is being operated by the named insured or any relative.

Exclusions

This coverage does not apply to personal injury sustained by:

(a) any person while occupying a motor vehicle owned by such person with respect to which the coverage required by the New York Comprehensive Motor Vehicle Insurance Reparations Act is not in effect;

(b) any person while occupying, or while a pedestrian through being struck by, a motor vehicle owned by the named insured with respect to which additional personal injury protection coverage is not provided under this policy;

(c) any relative while occupying, or while a pedestrian through being struck by, a motor vehicle owned by such relative with respect to which additional personal injury protection coverage is not provided under this policy;

(d) any New York State resident other than the named insured or relative injured through the use or operation of a motor vehicle outside of New York State if such resident is the owner of a motor vehicle for which the coverage required by the New York Comprehensive Motor Vehicle Insurance Reparations Act is not in effect;

(e) any person while occupying a motorcycle;

(f) any person who intentionally causes his own personal injury; ¹⁶

(g) any person as a result of operating a motor vehicle while in an intoxicated condition or while his or her ability to operate the vehicle is impaired by the use of a drug (within the meaning of section 1192 of the New York Vehicle and Traffic Law) except that coverage shall apply to necessary emergency health services rendered in a general hospital, as defined in section 2801(10) of the New York Public Health Law, including ambulance services attendant thereto and related medical screening. However, where the person has been convicted of violating section 1192 of the New York Vehicle and Traffic Law while operating a motor vehicle in an intoxicated condition or while his or her ability to operate such vehicle is impaired by the use of a drug, and the conviction is a final determination, the company has a cause of action against such person for the amount of first party benefits that are paid or payable; ¹⁷ or

(h) any person while:

(i) committing an act which would constitute a felony, or seeking to avoid lawful apprehension or arrest by a law enforcement officer; ¹⁶

(ii) operating a motor vehicle in a race or speed test;¹⁶

(iii) operating or occupying a motor vehicle known to that person to be stolen; or ¹⁶

(iv) repairing, servicing, or otherwise maintaining a motor vehicle if such 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;¹⁶

(i) any person who is injured while, pursuant to article 44-B of the Vehicle and Traffic Law, the insured motor vehicle is being used or operated by a transportation network company driver; ¹⁸ or

(j) any person who is injured while the insured motor vehicle is being used or operated by a shared vehicle driver pursuant to article 40 of the General Business Law.¹⁹

Additional First-Party Benefits

Additional first-party benefits are payments equal to extended economic loss reduced by:

(a) 20 percent of the eligible injured person's loss of earnings from work, to the extent that the extended economic loss covered by this (Endorsement) ¹⁹ includes such loss of earnings;

(b) amounts recovered or recoverable on account of personal injury to an eligible injured person under State or Federal laws providing social security disability or workers' compensation benefits or disability benefits under article 9 of the New York Workers' Compensation law, which amounts have not been applied to reduce first-party benefits recovered or recoverable under basic economic loss;

(c) amounts recovered or recoverable by the eligible injured person for any element of extended economic loss covered by this (Endorsement) ¹⁹ under any mandatory source of first-party automobile no-fault benefits required by the laws of any state (other than the State of New York) of the United States of America, its possessions or territories, or by the laws of any province of Canada.

Extended Economic Loss

Extended economic loss shall consist of the following:

(a) basic economic loss sustained on account of an accident occurring within the United States of America, its possessions or territories, or Canada, which is not recovered or recoverable under a policy issued in satisfaction of the requirements of article 6 or 8 of the New York Vehicle and Traffic law and article 51 of the New York Insurance Law;

(b) the difference between

(i) basic economic loss; and

(ii) basic economic loss recomputed in accordance with the time and dollar limits; ¹⁹ and

(c) an additional death benefit in the amount set out in the declarations) ²⁰

Two or More Motor Vehicles Insured Under This Policy

The limit of liability under this (Endorsement) ¹⁹ applicable to injuries sustained by an eligible injured person while occupying, or while a pedestrian through being struck by, the insured motor vehicle shall be as stated (in the declarations) ¹⁹ for that insured motor vehicle. The limit of liability for injuries covered by this (Endorsement) ²¹ and sustained by an eligible injured person while occupying, or while a pedestrian through being struck by, a motor vehicle, other than the insured motor vehicle, shall be the highest limit stated for this coverage in the declarations for any insured motor vehicle under this policy.

Arbitration

In the event any person making a claim for additional first-party benefits and the Company do not agree regarding any matter relating to the claim, such person shall have the option of submitting such disagreement to arbitration pursuant to procedures promulgated or approved by the Superintendent of Financial Services.

Subrogation

In the event of any payment for extended economic loss, the Company is subrogated to the extent of such payments to the rights of the person to whom, or for whose benefit, such payments were made. Such person must execute and deliver instruments and papers and do whatever else is necessary to secure such rights. Such person shall do nothing to prejudice such rights.

Other Coverage; Nonduplication

The eligible injured person shall not recover duplicate benefits for the same elements of loss covered by this (Endorsement) ²² or any other optional first-party automobile or no-fault automobile insurance coverage.

If an eligible injured person is entitled to New York mandatory and additional personal injury protection benefits under any other policy, and if such eligible injured person is not entitled to New York mandatory personal injury protection benefits under this policy, then the coverage provided under this Additional Personal Injury Protection Endorsement (New York) shall be excess over such other New York mandatory and additional personal injury protection benefits.

When coverage provided under this (Endorsement) ²² applies on an excess basis, it shall apply only in the amount by which the total limit of liability of New York mandatory and additional personal injury protection coverage available under this policy exceeds the total limit of liability for any other applicable New York mandatory and additional personal injury protection coverage

Subject to the provisions of the preceding three paragraphs, if the eligible injured person is entitled to benefits under any other optional first-party automobile or no-fault automobile insurance for the same elements of loss covered by this (Endorsement) ²² this Company shall be liable only for an amount equal to the proportion that the total amount available under this ²² bears to the sum of the amounts available under this (Endorsement) ²³ and such other optional insurance, for the same element of loss.

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¹⁴ Companies may substitute the appropriate term, reference or language for the matter set out in parenthesis.

¹⁵ If the policy is being used to satisfy the financial responsibility requirements of article 44-B of the Vehicle and Traffic Law, then the Company may substitute the following language:

The company will pay first-party benefits to reimburse for basic economic loss sustained by an eligible injured person on account of personal injuries caused by an accident arising out of the use or operation of a motor vehicle, pursuant to article 44-B of the Vehicle and Traffic Law, by a transportation network company driver during the policy period and within the United States of America, its territories or possessions, or Canada. If the policy is a group policy under article 40 of the General Business Law, then the Company may substitute the following language: The company will pay first-party benefits to reimburse for basic economic loss sustained by an eligible injured person on account of personal injuries caused by an accident arising out of the use or operation of a motor vehicle through a peer-to-peer car sharing program during the peer-to-peer car sharing period, pursuant to article 40 of the General Business Law, during the policy period and within the United States of America, its territories or possessions, or Canada.

¹⁶ These exclusions may be deleted, in the event the Company wishes to provide coverage under the indicated circumstances.

¹⁷ This exclusion may be deleted, in the event the company wishes to provide coverage under the indicated circumstance. Alternatively, the company may delete the cause of action language only, provided, however, that, in either case, if the company deletes this language, then the company will be deemed to have waived its right to bring a cause of action against the person.

¹⁸ An insurer may not include this exclusion in a policy used to satisfy the requirements under article 44-B of the Vehicle and Traffic Law. An insurer may use one of the following exclusions:

If the policy provides liability coverage while, pursuant to article 44-B of the Vehicle and Traffic Law. the insured motor vehicle is being used or operated by a transportation network company driver while providing a transportation network company prearranged trip:

any person who is injured while, pursuant to article 44-B of the Vehicle and Traffic Law, the insured motor vehicle is being used or operated by a transportation network company driver while the driver is logged onto a transportation network company's digital network but is not engaged in a transportation network company prearranged trip.

If the policy provides liability coverage while, pursuant to article 44-B of the Vehicle and Traffic Law, the insured motor vehicle is being used or operated by a transportation network company driver while logged onto a transportation network company's digital network but who is not engaged in a transportation network company prearranged trip:

any person who is injured while, pursuant to article 44-B of the Vehicle and Traffic Law, the insured motor vehicle is being used or operated by a transportation network company driver while the driver provides a transportation network company prearranged trip.

¹⁹ This exclusion may be deleted in the event the Company wishes to provide coverage under the indicated circumstance. An insurer may not include this exclusion in a policy used to satisfy the requirements under article 40 of the General Business Law.

²⁰ Companies may substitute the appropriate term, reference or language for the matter set out in brackets.

²¹ Language in brackets may be deleted if additional death benefits are not offered.

²² Companies may substitute the appropriate term, reference or language for the matter set out in brackets.

²³ Companies may substitute the appropriate term, reference or language for the matter set out in brackets.

²⁴ Companies may substitute the appropriate term, reference or language for the matter set out in brackets.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-1.3

Amended New York State Register October 25, 2017/Volume XXXIX, Issue 43, eff. 10/25/2017

Amended New York State Register February 8, 2023/Volume XLV, Issue 06, eff. 2/8/2023