Injuries Covered Under New York Car Insurance

Understanding No-Fault Insurance (PIP) in New York

New York is a no-fault car insurance state, governed by Article 51 of the Insurance Law. This system is designed to provide swift medical and economic relief to individuals injured in automobile accidents, regardless of who caused the crash. The cornerstone of this system is Personal Injury Protection, or PIP coverage. Every standard New York auto insurance policy must include a minimum of $50,000 in PIP benefits per person. This coverage is primary and pays out immediately following a qualified accident.

PIP covers a wide array of expenses for the policyholder, resident relatives, passengers, and pedestrians struck by the insured vehicle. It is crucial to understand its scope:

• Medical Expenses: This includes all necessary medical, surgical, dental, chiropractic, and rehabilitative services. It covers ambulance fees, emergency room treatment, hospital stays, surgery, physical therapy, prosthetics, and any other medically necessary treatment. There is no co-pay or deductible for these medical services under PIP.
• Lost Earnings: If injuries prevent an individual from working, PIP will reimburse 80% of lost wages, up to a maximum of $2,000 per month for up to three years from the date of the accident. There is a 30-day waiting period from the date of disablement before lost wage benefits begin.
• Other Necessary Expenses: PIP provides up to $25 per day for up to one year from the accident date for other reasonable and necessary expenses incurred because of the injury. This can include costs for household help, transportation to medical appointments (mileage or other means), and essential services the injured person can no longer perform.
• Death Benefit: A $2,000 death benefit is payable to the estate of anyone killed in an auto accident, in addition to any other applicable insurance benefits.

The Serious Injury Threshold and Liability Claims

While the no-fault system handles most claims, it intentionally limits the right to sue for pain and suffering. An injured person can only step outside the no-fault system and file a liability lawsuit against the at-fault driver if they have sustained a “serious injury” as defined by New York law.

Insurance Law § 5102(d) defines a “serious injury” as one that results in:

• Death
• Dismemberment
• Significant disfigurement
• A fracture
• Loss of a fetus
• Permanent loss of use of a body organ, member, function, or system
• Permanent consequential limitation of use of a body organ or member
• Significant limitation of use of a body function or system
• A medically determined injury or impairment of a non-permanent nature which prevents the injured person from performing substantially all of the material acts which constitute such person’s usual and daily activities for not less than 90 days during the 180 days immediately following the occurrence of the injury or impairment.

Successfully proving a “serious injury” is a complex legal hurdle. It requires extensive medical documentation and often the testimony of medical experts to establish the permanency or significance of the injury. If this threshold is met, the injured party can pursue a traditional tort claim against the at-fault driver’s bodily injury liability (BIL) coverage. This claim can seek compensation for:

• Pain and suffering, both past and future.
• Full lost wages (not limited to 80%).
• Future loss of earning capacity.
• Medical expenses that exceed the PIP policy limits.
• Loss of enjoyment of life.

Additional Insurance Coverages for Injuries

Beyond PIP and BIL, several other key insurance coverages in a New York policy can provide crucial benefits for injuries.

• Bodily Injury Liability (BIL): This is required coverage for all New York drivers, with minimum limits of $25,000 per person and $50,000 per accident. It does not cover the policyholder’s own injuries. Instead, it provides protection if the policyholder is found at fault in an accident and sued by another party who has met the serious injury threshold. It pays for the other party’s medical expenses, lost wages, and pain and suffering up to the policy limits.
• Supplementary Uninsured/Underinsured Motorist Coverage (SUM): This is an optional but critically important coverage. SUM protects you and your passengers if you are injured by a driver who has no insurance (uninsured) or whose insurance limits are too low to cover the full extent of your damages (underinsured). If you have a serious injury claim that exceeds the at-fault driver’s policy limits, your own SUM coverage can provide the difference, up to the limit you purchased. For example, if you have $100,000 in SUM coverage and the at-fault driver only has $25,000, you could potentially access an additional $75,000 from your own policy.
• Optional Basic Economic Loss (OBEL): Drivers can choose to purchase additional first-party no-fault benefits beyond the standard $50,000 PIP. This OBEL coverage increases the available limit for medical expenses and lost wages, providing a greater safety net without needing to prove a serious injury.
• Medical Payments Coverage (MedPay): While less common in New York due to its robust PIP system, MedPay is an optional coverage that can help pay for medical expenses for you and your passengers, regardless of fault. It can sometimes be used to cover co-pays or expenses that exceed PIP limits.

The Claims Process and Critical Steps

Navigating the claims process correctly is essential for securing benefits.

1. Seek Immediate Medical Attention: Your health is the priority. A medical professional can properly diagnose your injuries, and their records become vital evidence for your PIP and any potential serious injury claim.
2. File an Application for No-Fault Benefits (NF-2): You must notify your own insurance company of the accident and file a formal no-fault application within 30 days of the incident. Failure to meet this strict deadline can result in a complete denial of PIP benefits. This form requires details about the accident, your injuries, and your employment.
3. Cooperate with the Insurance Company: The insurer has the right to request an Independent Medical Examination (IME) to verify the nature and extent of your injuries. They may also request other documentation, such as proof of lost wages. Failure to attend an IME can lead to benefit termination.
4. Document Everything: Keep a detailed file of all medical bills, reports, receipts for other expenses, correspondence with insurance companies, and a journal documenting your pain, recovery progress, and how the injury impacts your daily life.
5. Consult an Attorney for Serious Injuries: If your injuries appear to meet the “serious injury” threshold, consulting with a personal injury attorney is highly advisable. They can navigate the complex legal process, handle negotiations with the at-fault party’s insurer, and ensure you are fully compensated for all your damages.

Common Exclusions and Limitations

PIP coverage is broad, but it is not unlimited. Key exclusions include:

• Intentional Self-Injury: Injuries intentionally caused by the insured person.
• Injuries During Commission of a Felony: Injuries sustained while committing a felony.
• Driving While Intoxicated: Injuries sustained while operating a vehicle under the influence of drugs or alcohol. However, PIP will still cover innocent passengers injured in the same vehicle.
• Driving Without Reasonable Belief of Being Entitled: Injuries sustained while driving a vehicle without a reasonable belief of being entitled to do so (e.g., in a stolen vehicle).
• Motorcycles: PIP does not cover injuries to the operator or passenger of a motorcycle. However, motorcyclists are required to carry their own similar coverage, often called “Motorcyclist Injury” coverage.
• Work-Related Injuries: If the injury is covered by workers’ compensation, that coverage becomes primary, and PIP acts as a secondary payer for certain uncovered expenses like co-pays.