New York Personal Injury Protection (PIP) Law requires drivers to carry Personal Injury Protection coverage as part of their auto insurance policy. PIP Law in New York operates on a no-fault basis, allowing injured drivers and passengers to receive compensation from their own insurer after a motor vehicle accident, regardless of fault. This structure prioritizes immediate access to medical care and income benefits without waiting for liability determinations.
Personal Injury Protection in New York covers reasonable and necessary medical expenses, lost earnings, replacement services, and funeral expenses, subject to statutory limits. New York law mandates a minimum of $50,000 in PIP benefits per person per accident, unless higher limits are selected. This requirement is defined under New York Insurance Law § 5102(a) and § 5103(a).
Personal Injury Protection law in New York plays a central role in auto injury claims by governing benefit eligibility, claim procedures, and insurer obligations. Mistakes involving notice, documentation, or statutory deadlines often delay benefits and increase disputes. Attorneys handling New York PIP claims rely on precise knowledge of the law to secure timely payments and protect clients’ rights from the outset.
Legal Status of Personal Injury Protection (PIP) Law in New York
New York fully adopts the Personal Injury Protection law through state statute. It forms the foundation of the state’s no-fault automobile insurance system. Every registered motor vehicle must carry PIP coverage unless a narrow statutory exemption applies.
Personal Injury Protection law in New York is statutory, not constitutional. The governing authority is found in Article 51 of the New York Insurance Law, commonly known as the Comprehensive Motor Vehicle Insurance Reparations Act. Core provisions appear in Insurance Law §§ 5101-5109. These statutes define mandatory coverage, benefit limits, eligibility rules, and insurer obligations. Courts interpret PIP disputes strictly in accordance with the legislative language and statutory intent.
Federal law does not preempt New York’s PIP framework. Regulation of automobile insurance remains a state power under the McCarran–Ferguson Act. Federal programs such as Medicare, Medicaid, and ERISA-governed health plans may affect benefit coordination. Still, New York Insurance Law controls payment priority, reimbursement rights, and claim procedures in most PIP cases.
Key New York Statutes, Codes, and Regulations Governing PIP Law
New York Personal Injury Protection (PIP) Law is governed by a comprehensive statutory and regulatory framework that defines coverage, benefits, claim procedures, and enforcement standards.
Primary Statutory Authority
- New York Insurance Law § 5101 – Establishes the purpose of the no-fault system and defines covered persons and losses.
- New York Insurance Law § 5102 – Defines “basic economic loss,” including medical expenses, lost earnings, and replacement services.
- New York Insurance Law § 5103 – Requires mandatory PIP coverage in all motor vehicle liability policies issued in New York.
- New York Insurance Law § 5104 – Limits lawsuits for non-economic loss unless a claimant meets the statutory serious injury threshold.
- New York Insurance Law § 5105 – Governs loss transfer and reimbursement rights between insurers.
- New York Insurance Law § 5106 – Establishes claim payment timelines, interest penalties, and attorney fee provisions for overdue benefits.
- New York Insurance Law § 5108 – Authorizes fee schedules and cost controls for medical services paid under PIP.
- New York Insurance Law § 5109 – Provides rulemaking authority related to no-fault insurance enforcement.
Regulatory Framework
- 11 NYCRR Part 65 (Regulation 68) – Details claim submission requirements, verification procedures, timeframes, and dispute resolution rules.
- 11 NYCRR § 65-3 – Sets strict deadlines for claim acknowledgement, verification requests, and benefit payment or denial.
- New York Department of Financial Services (DFS) – Oversees insurer compliance, policy forms, and claim handling under the PIP Law of New York.
State Regulatory and Enforcement Authorities in New York
New York PIP operates under strict regulatory oversight, with multiple agencies enforcing compliance and resolving disputes.
New York State Department of Financial Services (DFS)
DFS is the primary authority for PIP insurance. Responsibilities include:
- Approving no-fault policy forms
- Enforcing compliance with Insurance Law §§ 5101–5109
- Monitoring insurer claims practices
- Investigating complaints about delayed, denied, or underpaid benefits
- Imposing administrative penalties
DFS also issues guidance, circular letters, and enforcement actions shaping insurer and provider practices.
DFS Office of General Counsel & Enforcement
Handles:
- Interpreting statutes and regulations
- Prosecuting systemic violations
- Pursuing penalties for bad-faith claim handling
- Enforcing 11 NYCRR Part 65
New York State Courts
Courts enforce PIP compliance in cases involving:
- Denied or late claims (Insurance Law § 5106)
- Fee schedule disputes (Insurance Law § 5108)
- Fraud defenses and EUO compliance
New York State Department of Health (DOH)
While not a direct PIP regulator, DOH oversees:
- Provider licensing and scope of practice
- Fraud investigations tied to medical billing
Inter-Agency Coordination
DFS, courts, law enforcement, and medical licensing authorities work together to ensure compliance and maintain regulatory scrutiny.
Mandatory Coverage Limits and Benefits Under New York PIP Law
New York mandates Personal Injury Protection (PIP), referred to statutorily as “basic economic loss” for all registered motor vehicles. Coverage requirements are uniform statewide and strictly enforced.
Minimum Mandatory PIP Coverage
Under New York Insurance Law § 5102(a), every auto policy must provide at least $50,000 per person in basic economic loss benefits.
This coverage applies regardless of fault and is payable to:
- Drivers
- Passengers
- Pedestrians struck by a motor vehicle
What the $50,000 Covers
Basic PIP benefits include the following categories:
1. Medical Expenses
- 100% of reasonable and necessary medical treatment
- Subject to the New York No-Fault Fee Schedule
- Includes hospital care, diagnostics, rehabilitation, and certain prescription costs
2. Lost Wages
- Up to 80% of lost earnings
- Capped at $2,000 per month
- Payable for up to three years from the date of the accident
3. Other Necessary Expenses
- Up to $25 per day
- Covers transportation, household help, and similar accident-related costs
- Payable for up to one year
4. Death Benefit
- $2,000 death benefit payable to the decedent’s estate
- Separate from the $50,000 aggregate limit
Optional Additional PIP Coverage (APIP)
New York allows insureds to purchase Additional Personal Injury Protection (APIP) beyond the statutory minimum.
APIP may increase:
- Total coverage limits above $50,000
- Monthly wage loss caps
- Duration of wage replacement benefits
These enhancements are contractual and vary by policy.
Benefit Priority and Exhaustion
PIP benefits are paid:
- On a first-party basis
- Before any bodily injury liability claims
- Until the $50,000 limit is exhausted
Once PIP limits are exhausted, claimants may pursue:
- Health insurance coverage
- Bodily injury liability claims (if the serious injury threshold is met)
Strict Payment Timelines
Insurers must comply with Insurance Law § 5106(a) and 11 NYCRR § 65-3, including:
- 30-day payment or denial deadline
- Mandatory interest and attorney’s fees for late payments
Failure to comply exposes insurers to statutory penalties.
Rights and Obligations Under New York PIP Law
The New York Personal Injury Protection law creates statutory rights for injured parties and imposes strict compliance duties on claimants, providers, and insurers. These obligations arise mainly under New York Insurance Law §§ 5102–5106 and 11 NYCRR Part 65.
Key Rights of Injured Claimants
Right to No-Fault Benefits Regardless of Fault
New York operates under a no-fault system. Claimants recover PIP benefits without proving negligence.
Authority:
- Insurance Law § 5104(a)
Right to Prompt Payment of Benefits
Insurers must pay or deny claims within strict timelines.
- 30 days after receipt of proof of claim
- Interest accrues on overdue payments
Authority:
- Insurance Law § 5106(a)
- 11 NYCRR § 65-3.8
Right to Medical and Wage Loss Coverage
Eligible claimants receive:
- Medical treatment expenses
- Lost earnings up to statutory limits
- Transportation costs related to care
Authority:
- Insurance Law § 5102(a)
Right to Arbitration or Litigation
Claimants may dispute denials through:
- No-fault arbitration
- Civil court action
Authority:
- Insurance Law § 5106(b)
Core Obligations of Claimants
Timely Notice of Claim
Claimants must submit a written notice within 30 days of the accident.
Authority:
- Insurance Law § 5106(a)
- 11 NYCRR § 65-2.4
Late notice risks claim denial unless there is a clear justification.
Medical Compliance
Claimants must:
- Seek medically necessary treatment
- Attend Independent Medical Examinations (IMEs)
- Submit to Examinations Under Oath (EUOs) when requested
Failure leads to benefit suspension.
Authority:
- 11 NYCRR §§ 65-1.1, 65-3.5
Accurate and Complete Documentation
Claimants must provide:
- Medical reports
- Wage verification
- Disability certificates
Incomplete or inconsistent submissions trigger verification delays or denials.
Obligations of Medical Providers
Providers must:
- Use approved No-Fault forms
- Bill under the New York fee schedules
- Submit claims within 45 days of service
Authority:
- 11 NYCRR §§ 65-3.3, 65-3.11
Non-compliance voids reimbursement rights.
Insurer Duties Under New York PIP Law
Insurers carry mandatory obligations:
- Timely claim processing
- Written denial with a statutory basis
- Good-faith investigation
Bad-faith delays expose carriers to:
- Interest penalties
- Attorney fees
- Arbitration losses
Authority:
- Insurance Law § 5106
- 11 NYCRR § 65-3.8
Consequences of Non-Compliance
Non-compliance triggers legal immediate implications:
- Missed IME results in benefit suspension
- Missed filing deadlines result in denial
- Defective denials result in insurer liability
New York courts enforce these rules strictly.
Common Violations and State-Specific Triggers in New York PIP Law
New York PIP disputes often arise from procedural missteps, documentation gaps, or misunderstandings of statutory requirements. Insurers and claimants face denials or delays when rules under Insurance Law §§ 5102–5106 and 11 NYCRR Part 65 are not followed.
Late or Incomplete Claim Submission
- Claims must be filed with full documentation within 30 days of the accident.
- Missing medical reports, wage verification, or proof of essential services triggers delays or denials.
Authority: Insurance Law § 5106(a); 11 NYCRR § 65-2.4
Failure to Attend Independent Medical Examinations (IMEs)
- Insurers can require IMEs under 11 NYCRR § 65-3.5.
- Non-attendance or refusal may result in suspension of benefits until compliance.
Incorrect or Incomplete Medical Billing
- Bills must comply with the New York No-Fault Fee Schedule.
- Use of unapproved CPT codes or duplicate billing results in partial or full denial.
Authority: 11 NYCRR § 65-3.3
Exceeding Statutory Coverage Limits
- PIP coverage is limited to $50,000 per person per accident unless higher limits were selected.
- Claims exceeding the policy limit are automatically reduced or denied.
Authority: Insurance Law § 5102(a)
Coordination Errors with Health Insurance
- Failure to coordinate PIP payments with Medicare, Medicaid, or private health insurance can result in improper benefit calculations.
- Duplicate reimbursement requests are frequently denied.
Authority: Insurance Law § 5105
Fraud or Misrepresentation
- Submitting false accident details, inflating injuries, or billing for unprovided services triggers penalties.
- Civil and criminal consequences can include fines, interest, and potential imprisonment.
Authority: Insurance Law § 5108; Penal Law § 175.30
Treatment Necessity Disputes
- Insurers may deny treatments deemed non-essential or excessive.
- Pain management, physical therapy, and elective procedures are closely scrutinized.
Authority: 11 NYCRR § 65-3.7
Why These Triggers Matter for Law Firms
- Most denials in New York arise from technical or procedural errors, not lack of coverage.
- Attorneys must track documentation, deadlines, IMEs, and billing compliance to protect client rights and ensure timely benefits.
Penalties, Claim Denials, and Enforcement Mechanisms Under New York PIP Law
New York enforces strict rules for Personal Injury Protection claims. Penalties and denials arise from non-compliance, late submissions, fraud, or statutory violations. Enforcement is primarily statutory, with oversight by insurers, DFS, and the courts.
Common Reasons for Claim Denial
- Late or incomplete documentation
Claims missing medical reports, wage verification, or essential service proof can be denied.
Authority: Insurance Law § 5106(a); 11 NYCRR § 65-2.4 - Failure to attend Independent Medical Examinations (IMEs)
Non-attendance or refusal suspends or halts PIP benefit payments.
Authority: 11 NYCRR § 65-3.5 - Exceeding statutory coverage limits
Benefits beyond $50,000 per person per accident (unless optional higher limits were purchased) are denied.
Authority: Insurance Law § 5102(a) - Non-medically necessary treatment
Procedures outside approved fee schedules or deemed unnecessary may be rejected.
Authority: 11 NYCRR § 65-3.7 - Fraud or misrepresentation
Submitting false accident details, inflating injuries, or billing for unprovided services can result in denial and legal consequences.
Authority: Insurance Law § 5108; Penal Law § 175.30
Penalties for Non-Compliance
- Interest on overdue payments
Insurers must pay interest for late PIP benefit payments.
Authority: Insurance Law § 5106(a) - Attorney’s fees
Claimants may recover reasonable attorney fees if the insurer fails to comply with statutory timelines.
Authority: Insurance Law § 5106(a) - Administrative sanctions
DFS may impose fines or corrective actions on insurers who systematically violate PIP rules.
Authority: 11 NYCRR § 65-3.8
Enforcement Mechanisms
- Department of Financial Services (DFS) Oversight
- Monitors insurer compliance with PIP rules
- Investigates complaints and can impose fines
- Civil Litigation
- Claimants may sue for unpaid benefits, interest, and attorney fees
- Courts interpret statutory provisions strictly and enforce compliance
- Regulatory Audits
- DFS periodically audits insurer claim files for errors, late payments, and improper denials
- Fraud Investigations
- Alleged misrepresentation or false billing can trigger criminal or civil penalties under Insurance Law § 5108 and Penal Law § 175.30
Enforcement, Litigation, and Hearings Under New York PIP Law
Enforcement of the New York Personal Injury Protection (PIP) Law relies on a combination of regulatory oversight and judicial remedies. The Department of Financial Services (DFS) monitors insurer compliance with statutory deadlines, proper claim processing, and adherence to fee schedules. DFS has the authority to issue fines, corrective actions, and cease-and-desist orders against insurers that violate PIP rules.
When disputes cannot be resolved administratively, claimants may pursue litigation in civil court. Courts evaluate claims under Insurance Law §§ 5102–5106 and related regulations, reviewing medical documentation, wage loss proof, and compliance with Independent Medical Examinations (IMEs) and Examinations Under Oath (EUOs).
Litigation typically addresses delayed or denied benefits, exceeding policy limits, disputes over medically necessary treatments, or alleged insurer bad faith. Courts can award statutory interest, attorney fees, and full benefit payments when violations are established.
For serious disputes, New York law allows claimants to seek both compensatory and limited punitive remedies if fraud or misrepresentation is involved, as outlined under Insurance Law § 5108 and Penal Law § 175.30. Administrative hearings and court interventions together ensure that PIP claimants receive timely, appropriate compensation while maintaining insurer accountability.
Appeals and Post-Decision Process Under New York PIP Law
New York PIP claimants and insurers both have structured options to appeal decisions. If a claim is denied, partially paid, or disputed, the claimant may request reconsideration or review with the insurer. Should the insurer maintain the denial, the claimant can escalate the matter to civil court under Insurance Law §§ 5106(b) and 5107, seeking full benefits, interest, and attorney fees.
Insurers also have the right to appeal if they dispute medical necessity, the scope of treatment, or claim eligibility. Administrative remedies include DFS intervention, where the Department may review claim handling and enforce compliance with statutory timelines and fee schedules. Courts review appeal filings based on submitted documentation, statutory compliance, and adherence to 11 NYCRR Part 65. Independent Medical Examinations (IMEs), Examinations Under Oath (EUOs), and detailed medical and wage records often play a pivotal role in these proceedings.
Post-decision, any party may enforce judgments, collect awarded benefits, or seek additional remedies for statutory interest and attorney fees if the opposing party fails to comply. The appeals and post-decision process ensure accountability, protect claimant rights, and maintain strict enforcement of New York PIP statutory requirements.
How New York Differs from Other States
- Strict statutory minimums: New York mandates $50,000 per person per accident for PIP, higher than many states with $10,000–$25,000 minimums.
- No-fault coverage for pedestrians: Unlike many states, New York extends PIP benefits to pedestrians injured by motor vehicles.
- Mandatory medical fee schedules: New York enforces detailed 11 NYCRR Part 65 fee schedules; some states have more flexible billing rules.
- Limited right to sue for non-economic damages: Only serious injuries meet the threshold for pain and suffering claims under Insurance Law § 5104(a).
- DFS regulatory oversight: New York’s Department of Financial Services actively audits insurers, a level of enforcement not seen in all states.
- IMEs and EUOs are standard procedural requirements: Missing these can suspend benefits immediately, whereas some states allow more leeway.
Practical Challenges for Law Firms Handling PIP in New York
- Tracking strict statutory deadlines for notice, proof of claim, and payment.
- Coordinating with insurers to ensure timely benefit disbursement under fee schedules.
- Preparing and submitting accurate wage loss and medical documentation to avoid denials.
- Ensuring client compliance with IMEs, EUOs, and medical requests to prevent suspension.
- Navigating serious injury threshold rules for pain and suffering claims.
- Handling disputes involving coordination with health insurance (Medicare, Medicaid, private plans).
- Staying updated on DFS guidance, circular letters, and fee schedule changes.
- Managing claims for out-of-state residents injured in New York, ensuring PIP coverage applies.
Conclusion
New York Personal Injury Protection (PIP) Law provides injured drivers, passengers, and pedestrians with critical no-fault benefits, including medical expenses, wage loss, and necessary services. Strict statutory requirements under Insurance Law §§ 5102–5106 and detailed regulatory oversight via 11 NYCRR Part 65 ensure timely, predictable compensation.
Law firms handling PIP claims must navigate deadlines, documentation, IMEs, and coordination with insurers to protect clients’ rights effectively. Understanding New York’s unique PIP framework, including coverage limits, procedural obligations, and enforcement mechanisms, empowers attorneys to secure benefits efficiently and minimize disputes, giving clients the best chance for fair recovery after motor vehicle accidents.
