N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-2.2

Current through Register Vol. 46, No. 45, November 2, 2024

Section 65-2.2 - Obligations of self-insurers

(a) In accordance with the provisions of article 51 of the New York Insurance Law and this Part, a self-insurer shall pay first-party benefits to reimburse for basic economic loss sustained by an eligible injured person on account of personal injuries caused by an accident arising out of the use or operation of a motor vehicle within the United States of America, its territories or possessions, or Canada.

(b) First-party benefits. First-party benefits, other than death benefits, are payments equal to basic economic loss, reduced by the following:

(1) 20 percent of the eligible injured person's loss of earnings from work to the extent that an eligible injured person's basic economic loss consists of such loss of earnings; and

(2) amounts recovered or recoverable on account of personal injury to an eligible injured person under State or Federal laws providing social security disability or workers' compensation benefits, or disability benefits under article 9 of the New York Workers' Compensation Law.

(c) Basic economic loss. Basic economic loss shall consist of medical expense, work loss, other expense and, when death occurs, a death benefit as provided in this section. Except for such death benefit, basic economic loss shall not include any loss sustained on account of death. Basic economic loss of each eligible injured person on account of any single accident shall not exceed $50,000, or $75,000 if the self-insurer elects to provide optional basic economic loss coverage, except that any death benefit shall be in addition thereto.

(d) If the self-insurer has elected to provide Optional Basic Economic Loss (OBEL) coverage, the eligible injured person or that person's legal representative may specify that the OBEL coverage will be applied to one of the following four options:

(1) basic economic loss;

(2) loss of earnings from work;

(3) psychiatric, physical or occupational therapy and rehabilitation; or

(4) a combination of paragraphs (2) and (3) of this subdivision.

(e) OBEL coverage shall apply after the initial $50,000 of basic economic loss has been exhausted.

(f) Medical expense. Medical expense shall consist of necessary expenses for:

(1) medical, hospital, surgical, nursing, dental, ambulance, X-ray, prescription drug and prosthetic services;

(2) psychiatric, physical and occupational therapy and rehabilitation;

(3) any nonmedical remedial care and treatment rendered in accordance with a religious method of healing recognized by the laws of New York; and

(4) any other professional health services.

These medical expenses will not be subject to a time limitation, provided that within one year after the date of the accident it is ascertainable that further medical expenses may be sustained as a result of the injury. Payments pursuant to this section for necessary medical expenses shall be subject to the limitations and requirements of section 5108 of the New York Insurance Law.

(g) Work loss. Work loss shall consist of the sum of the following losses and expenses, up to a maximum payment of $2,000 per month for a maximum period of three years from the date of the accident:

(1) loss of earnings from work which the eligible injured person would have performed had such person not been injured, except that an employee who is entitled to receive monetary payments, pursuant to statute or contract with the employer, or who receives voluntary monetary benefits paid for by the employer, by reason of such employee's inability to work because of personal injury arising out of the use or operation of a motor vehicle, shall not be entitled to receive first-party benefits for loss of earnings from work to the extent that such monetary payments or benefits from the employer do not result in the employee suffering a reduction in income or a reduction in such employee's level of future benefits arising from a subsequent illness or injury; and

(2) reasonable and necessary expenses sustained by the eligible injured person in obtaining services in lieu of those which such person would have performed for income.

(h) Other expenses. Other expenses shall consist of all reasonable and necessary expenses, other than medical expense and work loss, up to $25 per day for a period of one year from the date of accident causing injury.

(i) Death benefit. Upon the death of any eligible injured person, caused by an accident for which the self-insurer is required to provide first-party benefits pursuant to this section, the self- insurer will pay to the estate of such person a death benefit of $2,000.

(j) Eligible injured person. Subject to the exclusions and conditions set forth below, an eligible injured person is:

(1) the self-insurer (who is a natural person) and any relative who sustains personal injury arising out of the use or operation of any motor vehicle;

(2) the self-insurer (who is a natural person) and any relative who, on or after July 22, 1982, sustains personal injury arising out of the use or operation of any motorcycle while not occupying a motorcycle;

(3) any other person who sustains personal injury arising out of the use or operation of the self-insured motor vehicle in the State of New York while not occupying another motor vehicle; or

(4) any New York State resident who, on or after January 1, 1983, sustains personal injury arising out of the use or operation of the self-insured motor vehicle outside of New York State while not occupying another motor vehicle.

N.Y. Comp. Codes R. & Regs. Tit. 11 §§ 65-2.2