This week we discuss what can be done when a no-fault insurance company denies all or part of your claim.  It is important to remember that New York State law requires that an insurance company send you a written denial.  The insurance company must list on the denial the item or items that it will not pay for.  A denial usually is based upon the insurance company's own investigation or physician review.  The law allows the insurance company to deny your claim for several reasons.  For example, it may deny the claim because it believes the treatment is not a result of the motor vehicle accident, the treatment is no longer medically necessary, that you are able to return to work (if lost wages are an issue), or if you failed to attend a scheduled physical examination. 

You have a right to contest this denial.  There are essentially two ways to do so.  First, you can start a lawsuit against the insurance company.  Second, you can start an arbitration proceeding.  Many attorneys prefer arbitration because it should be a quicker and more efficient way to resolve the dispute.  The New York State Insurance Department has set up an arbitration process through the American Arbitration Association.  Once the proper application for arbitration is filed, the American Arbitration Association will set up an arbitration date and assign a single arbitrator to hear your dispute.  The arbitrator – usually an experienced attorney – is retained directly by the American Arbitration Association, not the insurance company.  The arbitrator will hear and decide your dispute.  At the hearing, you must produce all evidence, usually in the form of medical records, to support your claim.  It is advisable to have legal counsel represent you.  The insurance company will also be submitting evidence to support its denial. 

Once the arbitrator hears all of the proof, he or she will issue a written decision.  The arbitrator can award attorneys' fees and interest on the unpaid medical bills or lost wages.   Except in rare circumstances, the arbitrator's decision is not appealable to any court.  The American Arbitration Association has a master arbitrator appeal process, which can be utilized if you believe the arbitrator has unfairly determined your case. 

Like any contested matter, the key to succeeding at a no-fault arbitration is preparation.  The more proof you have, whether by medical records or live testimony, the better chance you have of succeeding.