The amendments to the regulations and what they mean to you.

Understanding the 2013 New York No-Fault Insurance Regulation Changes

On April 1, 2013, significant changes to New York’s no-fault insurance regulations took effect that fundamentally altered how personal injury protection (PIP) claims are handled throughout Long Island and New York City. These amendments to Insurance Regulation 68-C have far-reaching implications for accident victims, medical providers, and attorneys handling personal injury cases across Nassau County, Suffolk County, and the five boroughs.

The Official Regulatory Language

NEW YORK STATE DEPARTMENT OF FINANCIAL SERVICES FOURTH AMENDMENT TO 11 NYCRR 65-3 (INSURANCE REGULATION 68-C) CLAIMS FOR PERSONAL INJURY PROTECTION BENEFITS

I, Benjamin M. Lawsky, Superintendent of Financial Services of the State of New York, pursuant to the authority granted by Sections 202 and 302 of the Financial Services Law, Sections 301, 2601, 5221 and Article 51 of the Insurance Law, and Section 2407 of the Vehicle and Traffic Law, do hereby promulgate the following
Fourth Amendment to Subpart 65-3 of Title 11 of the Official Co pilation of Codes, Rules and Regulations of the State of New York (Insurance Regulation 68-C), to take effect on April 1, 2013, to read as follows:
(NEW MATTER IS UNDERSCORED; MATTER IN BRACKETS IS DELETED)
New subdivisions (o) and (p) are added to section 65-3.5 to read as follows:
(o) An applicant from whom verification is requested shall, within 120 calendar days from the date of the initial request for verification, submit all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply. The insurer shall advise the applicant in the verification request that the insurer may deny the claim if the applicant does not provide within 120 calendar
days from the date of the initial request either all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply. This subdivision shall not apply to a prescribed form (NF-Form) as set forth in Appendix 13 of this Title, medical examination request, or examination under oath request. This subdivision shall apply, with respect to claims for medical services, to
any treatment or service rendered on or after April 1, 2013 and with respect to claims for lost earnings and reasonable and necessary expenses, to any accident occurring on or after April 1, 2013.

(p) With respect to a verification request and notice, an insurer’s non-substantive technical or immaterial defect or omission, as well as an insurer’s failure to comply with a prescribed time frame, shall not negate an applicant’s obligation to comply with the request or notice. This subdivision shall apply to medical services rendered, and to lost earnings and other reasonable and necessary expenses incurred, on or after April 1, 2013.
Paragraph (3) of section 65-3.8(b) is amended to read as follows:
(3) Except as provided in subdivision (e) of this section, an insurer shall not issue a denial of claim form (NYS form N-F 10) prior to its receipt of verification of all of the relevant information requested pursuant to sections 65-3.5 and 65-3.6 of this Subpart (e.g., medical reports, wage verification, etc.). However, an insurer may issue a denial if, more than 120 calendar days after the initial request for verification, the applicant has not submitted all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply, provided that the verification request so advised the applicant as required in section 65-3.5(o) of this Subpart. This subdivision shall not apply to a prescribed form (NFForm) as set forth in Appendix 13 of this Title, medical examination request, or examination under oath request.

This paragraph shall apply, with respect to claims for medical services, to any treatment or service rendered on or after April 1, 2013, and with respect to claims for lost earnings and reasonable and necessary expenses, to any accident occurring on or after April 1, 2013.

Subdivisions (g) through (j) of section 65-3.8 are relettered subdivisions (i) through (l) and new subdivisions (g) and (h) are added to read as follows:
(g)(1) Proof of the fact and amount of loss sustained pursuant to Insurance Law section 5106(a) shall not be deemed supplied by an applicant to an insurer and no payment shall be due for such claimed medical services under any circumstances:

(i) when the claimed medical services were not provided to an injured party; or

(ii) for those claimed medical service fees that exceed the charges permissible pursuant to Insurance Law sections 5108(a) and (b) and the regulations promulgated thereunder for services rendered by medical providers.

(2) This subdivision shall apply to medical services rendered on or after April 1, 2013.

(h) With respect to a denial of claim (NYS Form N-F 10), an insurer’s non-substantive technical or immaterial defect or omission shall not affect the validity of a denial of claim. This subdivision shall apply to medical services rendered, and to lost earnings and other reasonable and necessary expenses incurred, on or after April 1, 2013.

Expert Legal Analysis: What These Changes Mean

What do they mean to you? Well, claims people are enamored with new “(o)” which allows reserves to be closed after the provider does nothing for more than 120 days following receipt of a verification demand. I consider gratuitously objecting also be the equivalent of doing nothing. There will be arbitration and litigation involving the following:

” …under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply.” Once the blanks are filled in, more informed decisions can be made as to what the 120-day rule really means.

Next, what about the repeal of Fair Price? Pretty simple.

I like the repeal of Mercury v. Encare. The First Department really angered the Department and common sense applied. Insurance Law 5108 is not precludable, or shall we say, proof of claim shall not be established if this statute is violated.

Regarding the issue involving the defective denials… The best way to read and understand this rule is to put it in the context of what it is ameliorating. I would look at every defective denial case that the Appellate courts (mostly Second Department Appellate Division) have held that the denial is defective and hold this provision of he regulation against the holdings. The smart practitioner will get his or her way if they use this provision of the regulation from that vantage point.

Breaking Down the Key Changes

These regulatory amendments represent some of the most significant changes to New York’s no-fault insurance system in years, particularly affecting how claims are processed for accidents occurring on Long Island’s busy highways, New York City’s congested streets, and throughout the metropolitan area.

The 120-Day Verification Rule

Perhaps the most impactful change is the new 120-day verification rule. Under the amended regulations, if an accident victim or their medical provider fails to provide requested verification within 120 calendar days of the initial request, insurance companies can deny the claim outright.

This change has particular significance for:

• Car accident victims in Nassau and Suffolk Counties who may be dealing with multiple insurance companies
• Motorcycle accident victims throughout New York City who often have complex injury patterns requiring extensive documentation
• Pedestrian accident victims who may be receiving treatment from multiple specialists across different hospital systems

Technical Defects No Longer Invalidate Denials

Another crucial change involves how insurance companies handle claim denials. Previously, minor technical errors or omissions in denial forms could invalidate the entire denial, giving claimants another opportunity to pursue their claims. Under the new regulations, “non-substantive technical or immaterial defects” no longer affect the validity of claim denials.

Impact on Different Types of Personal Injury Cases

Motor Vehicle Accidents

For victims of car accidents on the Long Island Expressway, Belt Parkway, or any of New York City’s major thoroughfares, these changes mean that prompt response to insurance verification requests is more critical than ever. Failure to provide requested documentation within the 120-day window could result in permanent claim denial.

Medical Provider Claims

Healthcare providers treating accident victims throughout the New York metropolitan area must now be extremely diligent about responding to verification requests. The regulation specifically states that claims will not be paid when medical services weren’t actually provided or when fees exceed permissible charges under Insurance Law sections 5108(a) and (b).

Lost Wage Claims

Workers injured in accidents who are seeking compensation for lost earnings must ensure their employers and payroll companies respond promptly to verification requests. This is particularly important for workers in New York City’s service industries or Long Island’s diverse economy.

Strategic Implications for Legal Practice

These regulatory changes require personal injury attorneys to adapt their practice strategies:

Immediate Documentation

Attorneys must now emphasize immediate and comprehensive documentation of all aspects of their clients’ claims. This includes ensuring that medical providers understand the new verification requirements and the consequences of non-compliance.

Client Communication

Clear communication with clients about the 120-day rule is essential. Clients must understand that their cooperation in providing requested documentation is not just helpful—it’s critical to the success of their claim.

Insurance Company Relations

The amendment regarding technical defects in denials means that insurance companies have more leeway in how they format and issue claim denials. Attorneys must focus on substantive rather than procedural challenges to denials.

Understanding “Control or Possession”

One of the most complex aspects of the new regulations involves the phrase “under the applicant’s control or possession.” This language will likely be the subject of significant litigation as courts determine exactly what types of documentation fall within a claimant’s control.

Examples might include:

• Personal medical records from treating physicians
• Employment records and tax documents for wage verification
• Insurance policies and coverage information
• Police reports and accident documentation

The Mercury v. Encare Implications

The regulation’s impact on the Mercury v. Encare decision represents a significant shift in how Insurance Law 5108 violations are handled. This change means that proof of claim cannot be established when medical providers violate fee schedule requirements, regardless of other factors.

Frequently Asked Questions

What happens if I miss the 120-day deadline?

If you fail to provide requested verification within 120 days and cannot show reasonable justification for the delay, your claim may be permanently denied.

Do these rules apply to all no-fault claims?

The rules apply to medical services rendered on or after April 1, 2013, and to accidents occurring on or after that date for wage loss and necessary expense claims.

Can I challenge a denial based on technical defects?

Under the new regulations, minor technical or immaterial defects no longer invalidate claim denials. Challenges must focus on substantive issues.

What constitutes “reasonable justification” for missing deadlines?

This phrase will likely be defined through case law, but may include situations involving hospitalization, mental incapacity, or circumstances beyond the claimant’s control.

How do these changes affect medical providers?

Medical providers must be more diligent about verification compliance and must ensure their fees comply with Insurance Law fee schedules.

Protecting Your Rights Under the New Regulations

Given the complexity and potential pitfalls of these new regulations, having experienced legal representation is more important than ever for accident victims throughout Long Island and New York City.

Immediate Response Required

The 120-day rule means that there’s no time to waste when dealing with insurance verification requests. An experienced attorney can ensure that all required documentation is provided promptly and completely.

Understanding Your Obligations

Knowing exactly what documentation is “under your control or possession” requires legal expertise. An attorney can help you understand your obligations and protect you from unreasonable demands.

Get Expert Legal Guidance

If you’ve been injured in an accident anywhere on Long Island or throughout New York City, don’t let the complexity of these new no-fault regulations jeopardize your claim. The experienced personal injury attorneys at the Law Office of Jason Tenenbaum have been helping accident victims navigate New York’s changing legal landscape for years.

We understand how these regulatory changes affect your case and can ensure that you meet all deadlines and requirements while fighting for the maximum compensation you deserve. Our team stays current with all developments in no-fault law and can provide the strategic guidance you need.

Call (516) 750-0595 today for a free consultation. We’ll review your case, explain how these regulatory changes affect your specific situation, and develop a strategy to protect your rights. Remember, with the new 120-day rule in effect, time is more critical than ever—don’t delay in getting the legal help you need.

Related Articles

• Understanding IME No-Shows in New York No-Fault Insurance: Rights, Consequences, and Strategic Considerations
• No-Fault Verification Requirements: When Partial Compliance Isn’t Enough
• Understanding Legal Defenses in New York No-Fault Insurance Cases
• The CPLR 3212(g) paradigm
• New York No-Fault Insurance Law

Legal Update (February 2026): Since this post’s publication in 2013, New York’s no-fault insurance regulations have undergone multiple amendments, particularly affecting sections 65-3.5, 65-3.6, and 65-3.8 of 11 NYCRR 65-3, as well as related provisions under Insurance Law sections 5106 and 5108. Fee schedules, reimbursement rates, and claims processing procedures have been subject to periodic updates and revisions. Practitioners should verify current regulatory provisions and fee schedule amounts, as the specific requirements and rates discussed in this 2013 analysis may no longer reflect current law.