Understanding New York’s One Year Rule in No-Fault Insurance Claims

Understanding New York’s One Year Rule in No-Fault Insurance Claims

If you’ve been injured in a car accident on Long Island or in New York City, understanding the complexities of New York’s no-fault insurance system can make the difference between receiving the compensation you deserve and having your claim denied. One of the most critical aspects of this system is the “one year rule” – a legal principle that determines whether an injury is considered “ascertainable” within the first year following an accident.

At Jason Tenenbaum New York Law, we’ve helped countless clients navigate these complex insurance disputes throughout Nassau County, Suffolk County, and the five boroughs of New York City. Our deep understanding of no-fault law ensures that your rights are protected and that insurance companies cannot unfairly deny legitimate claims based on technical defenses.

What Is the One Year Rule in New York No-Fault Law?

The one year rule is a fundamental concept in New York’s no-fault insurance system that determines whether an injury can be considered “ascertainable” within one year of the date of the accident. This rule is crucial because it affects whether an insurance company is obligated to pay for medical treatment and other no-fault benefits related to a particular injury.

Under New York Insurance Law Section 5102, an injury is considered “ascertainable” if a reasonable person could have discovered or should have discovered the existence of that injury within one year after the accident occurred. This doesn’t necessarily mean the full extent of the injury must be known, but rather that some manifestation of the injury should have been apparent or discoverable.

The Legal Framework Behind Ascertainability

The concept of ascertainability serves several important purposes in New York’s no-fault system:

• It provides insurance companies with reasonable notice of potential claims
• It prevents fraudulent claims from emerging years after an accident
• It ensures that medical records and evidence remain fresh and reliable
• It promotes prompt medical treatment and documentation

However, the application of this rule is not always straightforward, and insurance companies sometimes use it inappropriately to deny legitimate claims.

A Critical Court Decision: AP Orthopedics v. Allstate Insurance Co.

This is an interesting case involving the one-year rule. The Civil Court’s finding – and it would appear to be correct – is that a claims representative can make a threshold determination involving whether the existence of an injury is ascertainable within one year from the date of loss. This is because the underlying issue does not involve the causal relationship between the loss and the service, but whether a reasonable person could ascertain the existence of a particular injury within one year after the accident. Since this case does not involve a causal relationship issue, a lay person can presumptively make this initial determination.

Yet, as this case also demonstrates, nothing stops the plaintiff from presenting evidence to demonstrate, in rebuttal, that the injury was ascertainable within one year from the loss.

AP Orthopedics & Rehabilitation, P.C. v Allstate Ins. Co., 2010 NY Slip Op 20082 (Civ. Ct. Richmond Co. 2010)

Key Findings from the Court

The court provided several important clarifications about how the one year rule should be applied:

“For example, if an insured submitted expenses for a cervical injury and then three years later submitted expenses for a knee injury, the latter would not be ascertainable within in the meaning of section 5102. On the other hand, if the subsequent treatment was for cervical injury,” that injury would be ascertainable since expenses for treatment for that injury had been submitted to the insurer within the one-year period.” Id.

This example illustrates a crucial distinction: if you receive treatment for a specific type of injury (like a neck injury) within the first year, then future treatments for that same type of injury may be covered even if they occur later. However, completely new injuries that first manifest years later may not be ascertainable under the one year rule.

The Stanovich Standard

The court also referenced the important Stanovich case and its progeny:

“Thus, according to Stanovich and its progeny, it would appear that as long as the insurance company can prove that it received no claims for a shoulder injury within one year of the accident, it would prevail on its defense that a claim submitted for a shoulder injury some seven years after the accident was not ascertainable within one year of the accident.”

This demonstrates how insurance companies can use the one year rule defensively, but it also shows the importance of proper documentation and timely claim submission.

How Claims Examiners Apply the One Year Rule

One of the most significant aspects of the AP Orthopedics decision is its ruling about who can make ascertainability determinations:

“Thus, if within a year it is not clear with certainty or discoverable that further expenses may be incurred, the insurer is under no obligation to pay for services rendered way after a year has expired. This determination can be made by a claims examiner who reviews records submitted or denials made on claims within the first year of the accident.”

This ruling is important because it establishes that insurance companies don’t always need medical experts to make initial ascertainability determinations. A claims examiner can review the documentary evidence and make these threshold decisions.

However, this doesn’t mean that claims examiners have unlimited authority. As the court noted: “To hold otherwise, and require an insurance company to present a medical expert to validate a claim’s examiner’s testimony that the assignor failed to file any claims relating” to a particular injury would create an unnecessarily burdensome standard.

The Burden of Proof

While insurance companies can make initial ascertainability determinations through claims examiners, injured parties retain the right to challenge these determinations with evidence. The key is providing documentation that shows an injury was indeed ascertainable within the one-year period, even if formal claims weren’t submitted.

Practical Implications for Long Island and NYC Accident Victims

If you’ve been injured in an accident in Nassau County, Suffolk County, or anywhere in the New York City metropolitan area, the one year rule has several important implications for your case:

Document Everything Immediately

The most crucial step you can take is to seek medical attention immediately after an accident and ensure that all your injuries are properly documented. Even if symptoms seem minor initially, having them on record can be vital if they worsen over time.

Submit Claims Promptly

Don’t wait to submit no-fault claims. Even if you’re uncertain about the full extent of your injuries, submitting claims for any treatment you receive helps establish the ascertainability of your injuries within the one-year period.

Keep Detailed Medical Records

Maintain comprehensive records of all medical treatment, symptoms, and communications with healthcare providers. These records can be crucial in demonstrating that an injury was ascertainable within the required timeframe.

Don’t Accept Initial Denials Without Challenge

If an insurance company denies a claim based on the one year rule, don’t assume the decision is final. With proper legal representation, these denials can often be successfully challenged.

Common Misconceptions About the One Year Rule

Many accident victims have misconceptions about how the one year rule works:

Misconception 1: All Injuries Must Be Fully Diagnosed Within One Year

The law doesn’t require that injuries be fully diagnosed or that their complete extent be known within one year. It only requires that the existence of some injury be ascertainable.

Misconception 2: Late-Manifesting Symptoms Are Never Covered

While truly new injuries that first appear years later may not be covered, worsening of existing injuries or delayed manifestations of trauma sustained in the original accident may still be covered if properly documented.

Misconception 3: Insurance Company Decisions Are Final

Insurance companies often make initial determinations about ascertainability, but these can be challenged with proper evidence and legal representation.

How Jason Tenenbaum New York Law Can Help

At our Long Island and New York City practice, we have extensive experience handling complex no-fault insurance disputes, including cases involving the one year rule. Our approach includes:

• Thorough review of medical records and claim documentation
• Expert analysis of ascertainability issues
• Strategic challenge of improper claim denials
• Negotiation with insurance companies
• Litigation when necessary

We understand the nuances of New York’s no-fault system and know how to effectively argue that injuries were ascertainable within the required timeframe, even when insurance companies claim otherwise.

Frequently Asked Questions

Q: What happens if I didn’t see a doctor immediately after my accident?

A: While immediate medical attention is ideal, you may still have options. We can help analyze your case to determine if there’s evidence that your injuries were ascertainable within the one-year period through other means.

Q: Can an insurance company deny my claim years later based on the one year rule?

A: Yes, insurance companies can raise ascertainability defenses even years after an accident. However, these defenses can often be successfully challenged with proper legal representation.

Q: Does the one year rule apply to all types of injuries?

A: The rule applies broadly, but its application can vary depending on the specific circumstances of each case. Some injuries may have delayed manifestations that are still considered ascertainable within the original timeframe.

Q: What evidence do I need to prove ascertainability?

A: Evidence can include medical records, treatment notes, insurance claims, witness statements, and expert medical testimony. Each case requires a tailored approach based on the specific facts and available evidence.

Take Action Today

Don’t let insurance companies use technical defenses like the one year rule to deny you the compensation you deserve. The complexities of New York’s no-fault system require experienced legal representation to navigate successfully.

If you’re dealing with a denied no-fault claim or have questions about the ascertainability of your injuries, contact Jason Tenenbaum New York Law today. Our team has the knowledge and experience to protect your rights and fight for the compensation you deserve.

Call us now at 516-750-0595 for a free consultation. We serve clients throughout Long Island, including Nassau and Suffolk Counties, as well as all five boroughs of New York City. Don’t wait – your rights may be at stake, and time limits apply.

Remember, at Jason Tenenbaum New York Law, we don’t get paid unless you get paid. Let us fight for you and ensure that insurance companies honor their obligations under New York’s no-fault system.

Related Articles

• Understanding causation standards under New York’s 5102(d) requirements
• How to prove causation in New York accident cases
• Establishing causal relationship in personal injury claims
• Handling pre-existing injuries in no-fault insurance cases
• Personal Injury

Legal Update (February 2026): Since this post’s publication in 2010, New York Insurance Law Section 5102 and related no-fault regulations may have been subject to amendments or clarifications through regulatory updates, court decisions, or legislative changes. The “one year rule” provisions regarding ascertainable injuries could have been modified, and fee schedule adjustments may have affected related claim procedures. Practitioners should verify current statutory language and recent case law interpretations when advising clients on ascertainable injury requirements.