New York PIP Insurance: Coverage, Claims, and Disputes

New York PIP insurance, called no-fault coverage under state law, is a mandatory part of every auto policy issued in the state. If you’re injured in a car accident, your own insurer pays your medical bills and a portion of your lost wages regardless of who caused the crash, up to a minimum of $50,000 per person.¹ The trade-off is that you generally cannot sue the other driver for pain and suffering unless your injury meets a specific legal threshold set by statute.

Who Personal Injury Protection Covers

Coverage reaches further than the person named on the policy. Passengers in the insured vehicle are covered. Pedestrians and bicyclists struck by a car file against the insurance on the vehicle that hit them.² If the vehicle that hit you was a hit-and-run or uninsured, a pedestrian can claim under a household family member’s auto policy instead.

The named insured and household members also stay covered for crashes involving uninsured vehicles, and for accidents outside New York anywhere in the United States, its territories, or Canada, even in states without their own no-fault law.³

Motorcyclists are the major exception. The no-fault statute defines “motor vehicle” in a way that excludes motorcycles, so an injured rider or motorcycle passenger cannot claim PIP benefits.¹ Motorcycle policies still have to cover pedestrians the bike injures, but the rider is outside the no-fault system entirely.³ Motorcyclists aren’t bound by the serious injury threshold either, so they can sue an at-fault driver directly for any level of injury.

What PIP Pays For

The $50,000 minimum is a single pool covering three categories of economic loss.¹

Medical Expenses

All necessary medical costs are covered without a time limit, provided it’s clear within one year of the accident that further treatment will be needed. That includes hospital stays, surgery, dental work, prescriptions, X-rays, prosthetics, ambulance transport, nursing care, psychiatric treatment, and physical or occupational therapy when provided pursuant to a referral.¹ There’s no separate sub-cap; medical bills simply draw down the same $50,000 pool as everything else.

Lost Wages

PIP reimburses lost earnings up to $2,000 per month for up to three years from the date of the accident.⁴ A 20% statutory offset applies before payment, so the effective maximum you actually receive is $1,600 per month.⁵ The offset exists because PIP wage benefits aren’t taxed. If your employer keeps paying you through sick leave or disability, PIP won’t duplicate that income.

Other Reasonable Expenses

Costs like hiring someone to handle household chores you can no longer do, or paying for transportation to medical appointments, fall into a catch-all category capped at $25 per day for up to one year after the accident.¹

Separately, PIP provides a $2,000 death benefit payable to the estate of anyone who dies from injuries in a covered accident, in addition to any medical expenses already paid.⁶

Raising the Coverage Ceiling

The statutory $50,000 is called “basic economic loss.” A serious injury can burn through it quickly, and two optional coverages let you buy more.

Optional Basic Economic Loss (OBEL) adds $25,000 on top, bringing the total to $75,000. It kicks in only after you’ve exhausted the first $50,000. When you buy OBEL, you designate how the extra money is allocated among specific categories: lost earnings, psychiatric care, physical therapy, occupational therapy, or rehabilitation.⁷ That designation is locked in at purchase, so it’s worth thinking about which category you’re most likely to need.

Additional Personal Injury Protection (APIP) extends coverage beyond the basic or OBEL limits for an extra premium, and is particularly useful for higher earners or anyone with a condition that could require prolonged treatment.⁴ Check your declarations page to see which of these, if any, you currently carry.

Filing a Claim and the Deadlines That Matter

Filing begins with Form NF-2, the Application for Motor Vehicle No-Fault Benefits. Your insurer should send it after you report the accident, and it’s also available from the New York Department of Financial Services.⁸ The form asks for the date, time, and location of the accident, contact information for every medical provider treating you, and your employer’s information if you’re claiming lost wages. You’ll also sign an authorization letting the insurer verify medical and employment records. Send the completed form by certified mail with a return receipt; the date it arrives starts the insurer’s payment clock.

Three deadlines drive the system, and missing one can cost you the claim entirely:

Written notice of the claim must reach the insurer within 30 days of the accident. Limited exceptions exist only with clear, reasonable justification for the delay.²
Healthcare providers must submit their bills to the insurer within 45 days of the date services were rendered. A late bill can be denied outright, and the provider may not be able to bill you either.⁹
Lost wage claims must be submitted within 90 days.¹⁰

Providers usually handle their own billing, but you’re the one who loses benefits when a deadline slips. Keep a personal log of treatment dates and follow up.

What Happens After You File

Once the insurer has your completed proof of claim and any verification it requested, it has 30 calendar days to either pay or deny.¹¹ Payment made after that window is overdue and must include interest at 2% per month, calculated pro-rata, as long as the interest exceeds $5.¹² That interest accrues automatically. You shouldn’t have to ask.

The insurer can also require you to attend an Independent Medical Examination (IME) with a doctor it selects. This is where many claims break down. If the IME doctor concludes further treatment isn’t medically necessary, the insurer will use that opinion to cut off benefits. Worse, if you simply don’t show up, the insurer can deny all pending claims and refuse to cover future treatment tied to that accident.¹³ Payments already made can’t be clawed back, but everything going forward is at risk. Attend every scheduled IME.

When PIP Won’t Pay

Even under a valid policy, certain conduct disqualifies you from benefits. Insurers can deny coverage when a person:

Intentionally caused their own injury
Was driving while intoxicated or drug-impaired (emergency hospital treatment and ambulance service are still covered, but the insurer can sue the impaired driver to recoup every other dollar it paid)
Was committing a felony or fleeing law enforcement
Was racing or participating in a speed test
Was in a vehicle they knew was stolen
Owned the vehicle but had no insurance on it (this also applies to pedestrians struck by a vehicle they own but failed to insure)

A less obvious exclusion: auto mechanics and body-shop workers injured while repairing a vehicle on business premises are routed to workers’ compensation instead of PIP.³

When No Policy Applies: MVAIC

If you were injured in New York, live in New York, and no auto policy covers you, the Motor Vehicle Accident Indemnification Corporation (MVAIC) may pay PIP benefits in place of a private insurer. The typical scenario is a pedestrian struck by an uninsured car when no household member owns an insured vehicle. You can’t have been the owner or spouse of the owner of the uninsured vehicle involved, and if anyone in your household has an auto policy, you have to file with that insurer first. Hit-and-run accidents must be reported to police within 24 hours, and a Notice of Intention filed with MVAIC within 90 days. For identified but uninsured vehicles, the Notice of Intention deadline is 180 days.¹⁴

How PIP Interacts with Other Coverage

No-fault pays first. Your private health insurer isn’t obligated to cover car accident treatment until PIP benefits are exhausted or formally denied. If a provider bills health insurance prematurely, redirect the billing to no-fault so you don’t burn health insurance limits on injuries PIP should be paying for. Once the $50,000 pool (or $75,000 with OBEL) runs out, health insurance picks up remaining covered treatment.

If the accident happened on the job, workers’ compensation benefits for the same injury are offset against your PIP benefits. The statute reduces first-party benefits by any amounts recovered through workers’ comp.⁵ Workers’ comp payments also count toward exhausting the basic economic loss cap, so PIP can run out faster than expected when both systems are paying.

Disputing a Denial

When an insurer denies or underpays, the standard path is no-fault arbitration through the American Arbitration Association. You start it by filing Form AR-1, the Request for New York No-Fault Arbitration, with a $40 filing fee.¹⁵ You’ll send the insurer copies of everything you file and affirm that the disputed amounts are still unpaid and that no other arbitration or lawsuit is pending on the same issue.

If you lose, you can appeal to a master arbitrator within 21 days of the mailing of the award. The appeal must be in writing and state the specific grounds for review, and the claimant’s filing fee is $75. Master arbitration grounds include errors of law or an award exceeding policy limits; routine factual disagreements from the first hearing generally don’t qualify.¹⁶ The 2% monthly interest on overdue payments should be built into any award you win.¹²

Can You Still Sue the Other Driver

The no-fault bargain takes away your right to sue for pain and suffering unless your injury clears a statutory bar. Under Insurance Law Section 5104, you can’t recover non-economic damages from a negligent driver unless your injury qualifies as a “serious injury,” and you can’t sue for basic economic loss already covered by PIP.¹⁷

Section 5102(d) lists the categories that qualify:¹

Death
Dismemberment
Significant disfigurement
A fracture
Loss of a fetus
Permanent loss of use of a body organ, limb, function, or system
Permanent consequential limitation of use of a body organ or limb
Significant limitation of use of a body function or system
A non-permanent injury that prevents you from performing substantially all of your usual daily activities for at least 90 of the first 180 days after the accident

That last one, often called the 90/180-day rule, is the most commonly claimed and the most commonly contested. Proving it takes medical documentation tying the injury to the accident, consistent treatment through the period, and ideally statements from employers or others confirming you couldn’t function normally. Gaps in treatment are the fastest way to undermine the claim. Insurers routinely argue that if you weren’t seeing a doctor, you weren’t that impaired. A personal log tracking daily pain levels and activity restrictions helps fill in the record between medical appointments.

1
New York State Senate. New York Insurance Code 5102 – Definitions
2
Department of Financial Services. Consumer FAQs About No-Fault Insurance
3
New York State Senate. New York Insurance Code 5103 – Entitlement to First Party Benefits
4
Department of Financial Services. OGC Opinion No. 03-01-38 – No-Fault Additional Personal Injury Protection
5
Department of Financial Services. OGC Opinion No. 03-02-13 – No-Fault Insurance Coordination with Workers’ Compensation
6
New York Department of Financial Services. 11 NYCRR 65.11 – Rights and Liabilities of Self-Insurers
7
New York Codes, Rules and Regulations. 11 NYCRR 65-1.2 – Requirements for Optional Basic Economic Loss Coverage
8
New York State Department of Financial Services. Application for Motor Vehicle No-Fault Benefits
9
Department of Financial Services. OGC Opinion No. 03-02-13 – Time Requirement to Submit Medical Proof of Claim
10
Department of Financial Services. FAQs – No-Fault Insurance Regulation 68
11
Department of Financial Services. OGC Opinion No. 04-05-23 – Date of Issuance of No-Fault Denial
12
New York State Senate. New York Insurance Code 5106 – Fair Claims Settlement
13
New York State Courts. Failure to Attend a No-Fault IME
14
MVAIC. Do You Qualify
15
American Arbitration Association. New York No-Fault Arbitration
16
New York Codes, Rules and Regulations. 11 CRR-NY 65-4.10 – Review by Master Arbitrator
17
New York State Senate. New York Insurance Code 5104 – Causes of Action for Personal Injury