The following article was written by E. Gregory M. Cannarozzi, Counselor-at-Law, L.L.C. and can be found on New-Jersey-Lawyers.com
The law firm of E. Gregory M. Cannarozzi, Counselor-at-Law, L.L.C., emphasizes representation of all medical providers and patients with respect to no-fault claims. When an individual is injured in an automobile accident, pursuant to N.J.S.A. 39:6A-1 et seq. the New Jersey No-Fault Statute, s/he is entitled to PIP (personal injury protection) benefits, under certain conditions. The purpose of No-Fault Act is social legislation intended to provide insureds with the prompt payment of medical bills, loss wages, and other such expenses without making them wait the outcome of protracted litigation in Court. In theory, PIP coverage is to be given the broadest application consistent with the statutory language of no-fault legislation, meaning that the fault system is to be removed from automobile negligence providing a minimum amount of protection to the public for injuries caused by an automobile accident. The system was designed to shift compensation from a tort and/or a third-party insurance to a system of first- party coverage.
In 1998, the New Jersey Legislature passed the Automobile Insurance Cross Reduction Act (“AICRA”) effective March 22, 1999. Under that Act, three types of insurance were provided: (1) basic insurance policies; (2) standard insurance policies; and (3) special insurance policies for eligible low income individuals.
The basic insurance policy provides only for very limited medical coverage and other PIP benefits such as income continuation, essential services and death benefits are not included.
In the special insurance policy for eligible low income individuals, there is even a more limited medical coverage than the basic policy, but it does allow for a $10,000.00 death benefit.
With respect to the standard policy, the Act provides for all the coverages that were formerly considered to be basic, including $250,000.00 in medical coverage, income continuation benefits, and funeral expenses. Extended options are also available for an extra premium.
Normally, when an individual is injured in an automobile accident, the injured party provides the medical provider with an Assignment of Benefits. This form permits the medical provider to treat the individual to the extent the medical provider deems appropriate and then file a claim, standing in the patient’s shoes so to speak, generally, for unpaid medical expense benefits. Under the New Jersey law, an individual is required to pay the selected policy deductible and 20% co-pay up to $5,000.00 ($1,000.00). Thereafter, the injured party’s insurance company is responsible for payment of medical expense benefits up to a ceiling of $250,000.00, for all medically necessary treatment of “permanent or significant brain injury, spinal cord injury or disfigurement or for medically necessary treatment of other permanent or significant injuries rendered at a trauma center or acute care hospital immediately following the accident and until the patient is stable.”
The New Jersey No-Fault System is a complicated process, which requires each medical provider to jump over many hurtles in order to recover payment for services rendered. In most situations, a medical provider must apply for pre-certification of services to be rendered, with certain exceptions. If the pre-certification request is not granted by the patient’s insurance company, then the medical provider is required to submit additional documentation and/or exhaust an internal appeal process with that patient’s auto insurer claims representative.
After the internal appeal period has transpired, if pre-certification is not granted, the medical provider will normally then retain the services of an attorney, such as this law firm, to file a no-fault arbitration claim, which, pursuant to AICRA, must be instituted with the National Arbitration Forum (NAF).
There are specific forms and rules promulgated by the NAF which apply to the filing, processing and execution of No-Fault claims in order to obtain an arbitration hearing. Depending on the severity of the claim, the medical provider will often testify either telephonically or in person at the arbitration hearing as the medical provider must prove the medical necessity, reasonableness, and causal relation to the accident for all medical services performed. The determination of the Dispute Resolution Professional (Arbitrator) is final and binding with limited rights for appeal.
Perfection of claims under the No-Fault Law in New Jersey has evolved into a very complex, time exhaustive, paper intensive process. Accumulating the proper medical documentation, as well as navigating through a morass of strict procedural requirements in ultimate payment of the claim in the No-Fault arbitration forum requires specialized skills and knowledge.
Since most insureds are unaware of either (1) which policy benefits they are entitled to under New Jersey No-Fault Law or (2) how to obtain treatment after their own insurance company denies benefits, it is essential that each injured individual contact an attorney well versed in no-fault arbitration claims in order to be fully protected.
The undersigned sat as a permanent No-Fault Arbitrator, now known as a Dispute Resolution Professional (“DRP”) from 1999 (when AICRA was first effected) until 2002; at that time the New Jersey no-fault claims forum was administered by the American Arbitration Association. The law firm has handled thousands of no-fault claims on behalf of both insureds and their medical providers in all areas of medicine. When any questions arise with respect to what benefits are available, the nature of a claim, and how it is prosecuted, it is extremely important to contact this law firm for advice so that your rights may be fully protected.
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