N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-2.4

Current through Register Vol. 46, No. 51, December 18, 2024

Section 65-2.4 - Conditions

(a) Action against self-insurer. No action shall lie against the self-insurer unless, as a condition precedent thereto, there shall have been full compliance with the terms of this section.

(b) Notice. In the event of an accident, written notice setting forth details sufficient to identify the eligible injured person, along with reasonably obtainable information regarding the time, place and circumstances of the accident, shall be given by or on behalf of each eligible injured person to the self-insurer or any of the self-insurer's authorized agents, as soon as reasonably practicable, but in no event more than 30 days after the date of the accident, unless the eligible injured person submits written proof providing clear and reasonable justification for the failure to comply with such time limitation. If an eligible injured person or that person's legal representative institutes a proceeding to recover damages for personal injury under section 5104(b) of the New York Insurance Law, a copy of the summons and complaint or other process served in connection with such action shall be forwarded as soon as practicable to the self-insurer or any of the self-insurer's authorized agents by such eligible injured person or that person's legal representative.

(c) Proof of claim; medical, work loss, and other necessary expenses. In the case of a claim for health service expenses, the eligible injured person or that person's assignee or legal representative shall submit written proof of claim to the self-insurer, including full particulars of the nature and extent of the injuries and treatment received and contemplated, as soon as reasonably practicable but, in no event later than 45 days after the date services are rendered. The eligible injured person or that person's legal representative shall submit written proof of claim for work loss benefits and for other necessary expenses to the self-insurer as soon as reasonably practicable but, in no event, later than 90 days after the work loss is incurred or the other necessary services are rendered. The foregoing time limitations for the submission of proof of claim shall apply unless the eligible injured person submits written proof providing clear and reasonable justification for the failure to comply with such time limitation. Upon request by the self-insurer, the eligible injured person or that person's assignee or representative shall:

(1) execute a written proof of claim under oath;

(2) as may reasonably be required submit to examinations under oath by any person named by the self-insurer and subscribe the same;

(3) provide authorization that will enable the self-insurer to obtain medical records; and

(4) provide any other pertinent information that may assist the self-insurer in determining the amount due and payable.

The eligible injured person shall submit to medical examination by physicians selected by, or acceptable to, the self-insurer, when, and as often as, the self-insurer may reasonably require.

(d) Arbitration. In the event any person making a claim for first-party benefits and the self- insurer do not agree regarding any matter relating to the claim, such person shall have the option of submitting such disagreement to arbitration pursuant to Subpart 64-5 of this Title.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-2.4