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The NYS NF 10 form plays a crucial role in the New York motor vehicle no-fault insurance system, specifically addressing the denial of claims by insurers. This form is designed for insurers to communicate their reasons for denying a claim, ensuring that applicants receive clear and detailed information about the decision. Key components of the form include the identification of the insurer, policyholder details, and the specifics of the accident. Insurers must provide a comprehensive breakdown of denied benefits, such as loss of earnings and health service expenses, along with the rationale for each denial. The form also outlines the options available to applicants who wish to contest the denial, including filing a complaint with the New York State Department of Financial Services or pursuing arbitration. Additionally, it highlights the importance of timely responses and proper documentation, which can significantly impact the outcome of a claim dispute. By understanding the NYS NF 10 form, applicants can navigate the complexities of the no-fault insurance system more effectively.
Similar forms
- Claim Denial Letter: Similar to the NYS NF 10 form, a claim denial letter communicates the reasons why an insurance claim has been rejected. It outlines specific policy provisions and provides the claimant with an opportunity to contest the denial, just as the NF 10 does.
- Proof of Loss Form: This document is used to formally notify an insurer of a claim and provide the details necessary for processing. Like the NF 10, it requires the claimant to provide comprehensive information about the incident and the losses incurred.
- Insurance Policy Declaration Page: This page summarizes the key details of an insurance policy, including coverage limits and exclusions. It serves as a reference point for understanding why a claim might be denied, similar to how the NF 10 outlines policy issues leading to denial.
- Request for Arbitration Form: When a claimant disagrees with a denial, they may submit this form to initiate arbitration. This process is mentioned in the NF 10, which also provides instructions on how to proceed if a claim is denied.
- Appeal Form: If a claim is denied, an appeal form allows the claimant to formally challenge the decision. This is akin to the NF 10, which advises claimants on their options to contest a denial.
Form Preview
NEW YORK MOTOR VEHICLE
DENIAL OF CLAIM FORM
TO INSURER: Complete this form, including item 33. Send two copies to applicant. Upon the request of the injured person, the insurer should send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person.
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF
For American Arbitration Association use
A. POLICYHOLDER |
B. POLICY NUMBER |
C. DATE OF ACCIDENT |
D. INJURED PERSON |
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E. CLAIM NUMBER |
F. APPLICANT FOR BENEFITS (Name and address) |
G. AS ASSIGNEE |
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YES |
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NO |
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TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL |
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YOU ARE ADVISED THAT FOR REASONS NOTED BELOW: |
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1. Your entire claim is denied as follows: |
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2. A portion of your claim is denied as follows: |
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A. Loss of Earnings |
$ |
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D. Interest |
$ |
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B. Health Service Benefits |
$ |
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E. Attorney's Fee |
$ |
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C. Other Necessary Expenses |
$ |
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F. Death Benefit |
$ |
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REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 33) |
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POLICY ISSUES |
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3.Policy not in force on date of accident
4.Injured person excluded under policy conditions or exclusion
5.Policy conditions violated:
a.No reasonable justification given for late notice of claim
b.Reasonable justification not
6.Injured person not an "Eligible Injured Person"
7.Injuries did not arise out of use or operation of a motor vehicle
8.Claim not within the scope of your election under Optional Basic Economic Loss coverage
LOSS OF EARNINGS BENEFITS DENIED
9.Period of disability contested: period in dispute From_______________Through_____________
10.Claimed loss not proven
11.Exaggerated earnings claim
of $______________per month denied
12.Statutory offset taken
13.Other, explained below
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
14.Amount of claim exceeds daily limit of coverage
15.Unreasonable or unnecessary expenses
16.Incurred after one year from date of accident
17.Other, explained below
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HEALTH SERVICE BENEFITS DENIED |
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18. |
Fees not in accordance with fee schedules |
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20. |
Treatment not related to accident |
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19. |
Excessive treatment, service or hospitalization |
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Unnecessary treatment, service or hospitalization |
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21. |
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From_______________Through_____________ |
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From_______________Through_____________ |
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Other, explained below |
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22. |
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COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED
23. Provider of Health Service (Name, Address and Zip Code) |
25. |
Period of bill - treatment dates |
29. Date final verification received |
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26. |
Date of bill |
30. |
Amount of bill |
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$ |
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24. Type of service rendered |
27. |
Date bill received by insurer |
31. |
Amount paid by insurer |
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$ |
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28. |
Date final verification requested |
32. |
Amount in dispute |
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$ |
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33. State reason for denial, fully and explicitly (attach extra sheets if needed):
DATE |
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Name and Title of Representative of Insurer |
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Telephone No. & Ext. |
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Name and address of Insurer claim processor (Third Party Administrator), if applicable |
Telephone No. & Ext. |
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NYS FORM
Page 1 of 3
DENIAL OF CLAIM FORM
IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS:
1.Should you wish to take this matter up with the New York State Department of Financial Services, you may file with the Department either on its website at http://www.dfs.ny.gov/consumer/fileacomplaint.htm or you may write to or visit the Consumer Assistance Unit, Financial Frauds and Consumer Protection Division, New York State Department of Financial Services, at: One State Street, New York, NY 10004; One Commerce Plaza, Albany, NY 12257; 163B Mineola Boulevard, Mineola, NY 11501, or Walter J. Mahoney Office Building, 65 Court Street, Buffalo, NY 14202.
Although the Department of Financial Services will attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed claim. If you wish to file a written complaint, send one copy of this Denial of Claim Form with copies of other pertinent documents with a letter fully explaining your complaint to the Department of Financial Services at one of the above addresses.
If you choose this option, you may at a later date still submit this dispute to arbitration or bring a lawsuit; or
2.You may submit this dispute to arbitration. If you wish to submit this claim to arbitration, then mail or
together with a $40 filing fee, payable by check, money order, or credit card to the American Arbitration Association (AAA) to:
AMERICAN ARBITRATION ASSOCIATION (AAA)
NEW YORK INSURANCE CASE MANAGEMENT CENTER 120 BROADWAY
NEW YORK, NEW YORK 10271
nyicmc.filingsubmissions@adr.org
Please contact the American Arbitration Association's customer service department at (917)
A complete copy of this filing, listing all bills and proofs as well as a table of contents listing your submissions must be provided to the AAA and the insurer at the time of filing for arbitration. The filing must be complete with all necessary documentation, as any late submission may not be admissible at arbitration. The filing fee will be returned to you if the arbitrator awards you any portion of your claim. However, you may be assessed the costs of the arbitration proceeding if the arbitrator finds your claim to be frivolous, without factual or legal merit or was filed for the purpose of harassing the respondent. The decision of an arbitrator is binding, except for limited grounds for review set forth in the Law and regulations promulgated thereunder.
If you are contesting the denial of claim and wish to submit the dispute to arbitration, state on accompanying sheets the reason(s) you believe the denied or overdue benefits should be paid. Attach proof of disability and verification of loss of earnings in dispute, sign below, and send the completed form to the American Arbitration Association at the address given in item 2 above.
Loss of earnings: |
Date claim made:_____________________ |
Gross earnings per month $______________________ |
Period of dispute: |
From ___________ Through _____________ |
Amount claimed: $_____________________________ |
Health Services: (Attach bills in dispute and list each one separately)
Name of Provider(s) |
Date of Service |
Amount of Bill |
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Amount in Dispute
Date Claim Mailed
Other Necessary Expenses: (Attach bills in dispute and list each one separately)
Type of Expenses Claimed |
Amount Claimed |
Date Incurred |
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Date Claim Mailed
Amount in Dispute
Other: (attach additional sheet if necessary)
·Upon your request, if you file for arbitration within 90 days of the date of this denial or the claim becoming overdue, your case will be scheduled for arbitration on a priority basis.
·You qualify for special expedited arbitration if the insurer has determined that your written justification for submitting late notice of claim failed to meet a “reasonableness standard”. Your specific request for special expedited arbitration must be filed within 30 days of the date of denial. Your filing must be complete and contain all information that you are submitting at the time of filing.
NYS FORM
Page 2 of 3
DENIAL OF CLAIM FORM
3.You may bring a lawsuit to recover the amount of benefits you claim to be entitled to.
THE UNDERSIGNED AFFIRMS AND CERTIFIES AS TRUE UNDER THE PENALTY OF PERJURY THAT THIS FILING IS BEING MADE IN GOOD FAITH AND THAT UPON INFORMATION, BELIEF AND REASONABLE INQUIRY THE DOCUMENTS BEING SUBMITTED HEREWITH ARE NOT FRAUDULENT AND THAT EXACT COPIES OF ALL DOCUMENTS PROVIDED HEREWITH HAVE BEEN MAILED TO THE INSURER AGAINST WHOM THE ARBITRATION IS BEING REQUESTED. UNLESS DISCLOSED WITH THIS SUBMISSION, THE DISPUTED AMOUNTS REMAIN UNPAID TO THE APPLICANT BY ANY PAYOR AND THERE HAS BEEN NO OTHER FILING OF AN ARBITRATION REQUEST OR LAWSUIT TO RESOLVE THE DISPUTED MATTERS CONTAINED IN THIS SUBMISSION.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
ARBITRATION REQUESTED BY:
LAST NAME |
FIRST NAME |
NAME OF LAW FIRM, IF ANY |
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TELEPHONE NUMBER: |
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FAX NUMBER: |
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EMAIL ADDRESS: |
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ADDRESS |
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ARE YOU AN ATTORNEY? |
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DATE |
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YES |
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NO |
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SIGNATURE |
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IMPORTANT NOTICE TO APPLICANT
If box number 3 ("Policy not in force on date of accident") on the front of this form is checked as a reason for this denial, you may be entitled to
your best interest to contact the M.V.A.I.C. immediately and file such an affidavit, even if you intend to contest this denial.
NYS FORM
Common mistakes
Filling out the NYS NF-10 form can be a straightforward process, but many people make common mistakes that can lead to delays or denials of their claims. One significant error occurs when applicants fail to provide complete information in the required fields. For instance, omitting details like the policy number or the date of the accident can result in the insurer being unable to process the claim efficiently. Always double-check that every section is filled out accurately before submitting the form.
Another frequent mistake is not clearly stating the reasons for the denial of the claim. In item 33, it’s crucial to provide a detailed explanation of why the claim is being contested. Insurers need this information to understand the context and specifics of the case. If this section is vague or incomplete, it can lead to misunderstandings and further complications in the claims process.
Many people also overlook the importance of keeping copies of all documents submitted. When sending the NF-10 form, it’s vital to retain a copy for your records. This practice not only provides a reference for future correspondence but also serves as proof of what was submitted. Without this, tracking the status of your claim can become challenging, especially if discrepancies arise later.
Lastly, failing to adhere to deadlines is a common pitfall. The form outlines specific time frames for contesting denials and filing for arbitration. Missing these deadlines can jeopardize your ability to receive benefits. Staying organized and setting reminders can help ensure that you meet all necessary timelines, keeping your claim on track.
More About Nys Nf 10
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What is the purpose of the NYS NF-10 form?
The NYS NF-10 form is used by insurers to formally deny a claim under the New York Motor Vehicle No-Fault Insurance Law. It outlines the reasons for the denial and provides the injured person with necessary information on how to contest the decision.
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Who needs to complete the NYS NF-10 form?
The insurer or self-insurer must complete the form. They are responsible for filling in all required fields, including details about the policyholder, the accident, and the injured person.
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What should I do if I receive a denial on my claim?
If you receive a denial, you have several options. You can contest the denial by following the instructions on the form. This includes filing a complaint with the New York State Department of Financial Services or submitting the dispute for arbitration with the American Arbitration Association.
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What are the common reasons for claim denial listed on the form?
Common reasons for denial include:
- The policy was not in force on the date of the accident.
- The injured person is excluded under policy conditions.
- The claim does not meet the criteria for an "Eligible Injured Person."
- Injuries did not arise from the use of a motor vehicle.
- Claims for loss of earnings or necessary expenses were not proven.
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How can I contest a denial of my claim?
You can contest a denial by either filing a complaint with the New York State Department of Financial Services or submitting your case for arbitration. If you choose arbitration, you must include all relevant documentation and pay a filing fee.
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What is the timeframe for filing a complaint or arbitration request?
You should file a complaint with the Department of Financial Services as soon as possible after receiving the denial. If you choose arbitration, you must submit your request within 90 days of the denial or the claim becoming overdue.
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What happens if I win my arbitration case?
If you win your arbitration case, the arbitrator may award you a portion or all of your claim. The filing fee will be returned to you if the arbitrator rules in your favor. However, if the claim is found to be frivolous, you may be responsible for the costs of the arbitration.
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What should I include when submitting my claim for arbitration?
When submitting your claim for arbitration, include the completed NYS NF-10 form, all pertinent documents, a table of contents, and any proof of disability or loss of earnings. Be sure to attach bills in dispute for health services and other necessary expenses.
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What is the role of the Motor Vehicle Accident Indemnification Corporation (M.V.A.I.C.)?
If your policy was not in force at the time of the accident, you may be entitled to No-Fault benefits from the M.V.A.I.C. It is advisable to contact them immediately and file an Affidavit of Intention to Make Claim, even if you plan to contest the denial.
Misconceptions
Misconceptions about the New York State No-Fault Insurance Denial of Claim Form (NYS NF-10) can lead to confusion and missteps in the claims process. Below are some common misconceptions, along with clarifications to help navigate this important document.
- Misconception 1: The insurer must provide a detailed explanation for every denial.
- Misconception 2: A denial means you cannot receive any benefits at all.
- Misconception 3: You have an unlimited amount of time to contest a denial.
- Misconception 4: The form can be filled out in any way you choose.
- Misconception 5: You can only contest a denial through arbitration.
- Misconception 6: If a claim is denied, you cannot receive any benefits from the Motor Vehicle Accident Indemnification Corporation (M.V.A.I.C.).
- Misconception 7: You must accept the insurer’s denial without question.
- Misconception 8: The arbitration process is always in favor of the insurer.
- Misconception 9: You do not need to keep records of your medical treatments or expenses.
While insurers are required to state the reasons for denial, they may not always provide extensive details. The form includes checkboxes for common reasons, which can sometimes be vague.
A denial may only pertain to specific parts of a claim. For example, if part of your claim for lost wages is denied, you might still be eligible for medical expenses.
There are strict deadlines for contesting a denial. Generally, you must act within 30 days to request arbitration or file a complaint with the New York State Department of Financial Services.
Completing the form correctly is essential. Each section must be filled out as instructed to avoid delays or additional denials.
While arbitration is one option, you can also file a complaint with the Department of Financial Services or pursue a lawsuit to recover benefits.
If your policy was not in force at the time of the accident, you may still be eligible for benefits from M.V.A.I.C., provided you file an Affidavit of Intention to Make Claim.
Claimants have the right to contest denials. Understanding your options can empower you to seek the benefits you deserve.
Arbitration is designed to be impartial. If you present a strong case with adequate documentation, the arbitrator may rule in your favor.
It is crucial to maintain thorough records of all medical treatments and expenses related to your claim. These documents are essential for contesting any denial.
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Key takeaways
When filling out and using the NYS NF-10 form, keep these key takeaways in mind:
- Complete All Required Information: Ensure that every section of the form is filled out accurately. Missing information can lead to delays or further denials.
- Understand Your Denial Reasons: Review the reasons for denial carefully. Each reason must be checked and explained in detail in item 33 to provide clarity and support your case.
- Know Your Options: If you wish to contest the denial, you can file a complaint with the New York State Department of Financial Services, submit for arbitration, or pursue a lawsuit. Each option has specific requirements and timelines.
- Document Everything: Keep copies of all documents submitted, including the denial form and any supporting evidence. This documentation is crucial for any further proceedings.
Nys Nf 10: Usage Guide
Completing the NYS NF-10 form is an essential step in addressing a denial of a claim under New York's No-Fault Insurance Law. This process requires careful attention to detail to ensure all necessary information is accurately provided. Following these steps will help facilitate the submission of the form.
- Begin by identifying the insurer or self-insurer. Fill in their name, address, and NAIC number.
- Provide details about the policyholder, including their name and policy number.
- Indicate the date of the accident and the name of the injured person.
- Fill in the claim number associated with the claim.
- Provide the applicant's name and address for benefits.
- Specify whether the applicant is an assignee by checking "Yes" or "No."
- Detail the reasons for the denial of the claim in the appropriate sections. Indicate if the entire claim is denied or if only a portion is denied, and specify the amounts for each category, such as loss of earnings, health service benefits, etc.
- Check all relevant reasons for denial and provide explanations in item 33.
- If applicable, complete items 23 through 32 for health service benefits that are denied, including the provider's information and treatment dates.
- Sign and date the form, including the name and title of the representative of the insurer.
- Make copies of the completed form. Send two copies to the applicant.
After submitting the form, the next steps involve either contesting the denial through arbitration or filing a complaint with the New York State Department of Financial Services. It is crucial to follow the outlined procedures to ensure that your dispute is properly addressed.