Who is insured

Benefits

Exclusions

Proof of claim

Added personal injury protection

Relation to other coverages

Tort liability

Who Is Insured

No-fault benefits under endorsement PP 05 87 are payable to “eligible injured persons.” The named insured and any relative (a person regularly residing in the named insured's household and related to the named insured by blood, marriage, or adoption, including wards and foster children) are eligible injured persons if the injury arises out of the use or operation of any motor vehicle, or of any motorcycle, as long as the named insured or the relative is not occupying the motorcycle. Any other person who sustains personal injury while not occupying another motor vehicle is an eligible injured person if the injury arises out of the use or operation of the insured motor vehicle within New York . Finally, any New York resident who sustains personal injury arising out of the use or operation of the insured motor vehicle outside of New York while not occupying another motor vehicle is an eligible injured person.

 Benefits

 The insurer pays first party benefits under the New York no-fault law to reimburse for basic economic loss. Basic economic loss consists of medical expense, work loss, other expenses, and a death benefit. The aggregate limit for recovery in the first three categories is $50,000 for any one injured person in any one accident.

 Medical expense coverage is for necessary medical, hospital, and surgical services, rehabilitation services, nursing, other professional health services that are provided, and any nonmedical remedial care and treatment rendered in accordance with a religious method of healing recognized by the laws of New York, subject to the $50,000 aggregate. No time limit governs recovery except that the need for any expenses must be ascertainable (although not necessarily incurred) within one year after the date of the accident in order for the expense to be covered under the policy.

 The work loss benefit category applies to loss of earnings from work the injured person would have performed if there had been no injury and to the reasonable and necessary expense of obtaining services in lieu of those the injured person would have performed for income.

 Work loss benefits cover up to a maximum payment of $2,000 per month. The benefit period extends for three years from the date of the accident. Benefits are reduced by the amount of any monetary benefits for income loss paid voluntarily or under statute or contract by the injured person's employer when such payments do not reduce the amount of similar benefits to which the injured person would be entitled for a future illness or injury.

 Other expenses are reasonable and necessary expenses—other than medical expenses and loss of income—up to a maximum of $25 per day for one year from the date of the accident.

 The death benefit of $2,000 is payable to the estate of an eligible injured person whose death is caused by an accident covered by no-fault insurance. The death benefit is not subject to the no-fault aggregate; that is, it is payable even if the entire $50,000 of the other no-fault benefits has been paid.

 Exclusions

 Endorsement PP 05 87 contains ten exclusions. Personal injury (defined on the endorsement as bodily injury, sickness, or disease) to the named insured is excluded from coverage if it occurs while the named insured is occupying a motor vehicle owned by the named insured but not covered by required no-fault insurance, or when the named insured is injured as a pedestrian by such a vehicle. A similar exclusion rules out coverage for any relative injured as an occupant of or as a pedestrian struck by a motor vehicle owned by the relative and not covered by required no-fault insurance.

 There is no coverage for the named insured or a relative injured as an occupant of or as a pedestrian when struck by a motor vehicle, other than the insured motor vehicle, on which required no-fault insurance is in effect for accidents occurring in the state of New York . The intent is that no-fault benefits for such injuries be provided by the insurance on the involved vehicle. This exclusion does not apply to (and the endorsement covers) injuries that occur on a bus or school bus, except to the operator or owner of the bus or an employee of either.

 In accordance with the scope of coverage required by statute, the endorsement excludes injury to any person while occupying a motorcycle (a vehicle, as defined in the traffic laws of New York).

 Another exclusion rules out coverage for anyone who intentionally causes his own personal injury. The endorsement also excludes coverage to any person injured as a result of operating a motor vehicle while in an intoxicated condition, or while the ability to operate a vehicle is impaired by the use of a drug. Any person while committing a felony or trying to avoid apprehension by the police, operating a motor vehicle in a race or speed test, or operating or occupying a motor vehicle with the knowledge that it is stolen is not insured for any personal injury sustained. The endorsement also excludes coverage for any person injured while repairing, servicing, or maintaining a motor vehicle if such conduct is within the course of a business and if the injury occurs on the business premises.

 Endorsement PP 05 87 does not cover personal injury sustained by the named insured or relative while not occupying a motor vehicle or a motorcycle when struck by a motorcycle in New York with respect to which the coverage required by the no-fault law is in effect. Also excluded is coverage for any New York resident, other than the named insured or relative, injured through the use or operation of the insured motor vehicle outside New York , if such resident is the owner or a relative of the owner of a motor vehicle insured under another policy providing the coverage required by the law. Finally, coverage is excluded for injury to any New York resident, other than the named insured or relative, injured through the use or operation of the insured motor vehicle outside New York if such resident is the owner of a motor vehicle for which no-fault coverage required by law is not in effect.

 Proof of Claim

If a claim is made for health services, the eligible injured person or his assignee or representative must submit a written proof of claim within forty-five days from the date services are rendered. A written proof of claim for work losses must be submitted within ninety days. The eligible injured person or his assignee or representative may be required by the insurer to execute a written proof of claim under oath, submit to examinations under oath, provide authorization for access to medical records, and provide other requested materials. The insurer may also require the eligible injured person to submit to medical examinations.

 Added Personal Injury Protection

 Coverage provided under the personal injury protection endorsement is increased and broadened at the option of the insured through the use of PP 05 88, the added personal injury protection coverage endorsement. This endorsement provides additional first-party benefits to reimburse for extended economic loss on account of personal injuries sustained and caused by an accident arising out of the use or operation of a motor vehicle or a motorcycle anywhere within the United States, its territories or possessions, or Canada; additional death benefit limits can also be set by this endorsement.

 “Extended economic loss” is defined in PP 05 88 as consisting of the basic economic loss (sustained on account of an accident) that is not recovered or recoverable, the difference between basic economic loss and limits set out in the schedule, and any additional death benefit in the amount that is stated in the schedule.

 PP 05 88 changes the definition of “eligible injured person” to a degree. The named insured and relatives as eligible injured persons remain the same; however, the “any other person” category is changed. Under PP 05 88, any other person who sustains personal injury arising out of the use or operation of the insured motor vehicle while occupying it is an eligible injured person; the operation of the motor vehicle does not have to be in New York, as under the basic no-fault coverage. Also, “eligible injured person” includes any other person who sustains personal injury arising out of the use or operation of any other motor vehicle (other than a public or livery conveyance) while occupying such vehicle, if such vehicle is being operated by the named insured or any relative of the named insured.

 Relation to Other Coverages

 New York no-fault benefits are reduced by the amount of any recovery under social security disability benefits or a workers compensation law; also, no-fault benefits are reduced by 20 percent of the eligible injured person's loss of earnings from work; finally, the benefits are reduced by any applicable deductible for the named insured and any relative. Medical payments and uninsured motorists coverage under an automobile policy are made excess when the policy is endorsed to provide no-fault coverage.

Duplicate recovery of no-fault benefits is prohibited under the personal injury protection endorsement. When two or more policies providing the basic required limits of coverage apply to a single injury, each contributes its maximum applicable limit divided by the number of contributing policies. When coverage is also available under the no-fault system of another state, New York mandatory no-fault coverage will pay an amount determined by the proportion that its limit bears to all applicable limits. If the other contributing no-fault policy provides unlimited benefits, the New York coverage will pay on the basis of contribution by equal shares until its $50,000 limit is exhausted.

Added personal injury protection coverage contributes with other available optional no-fault coverage according to the proportion of applicable limits. In instances when the eligible injured person may recover basic benefits under other New York no-fault insurance but not under the coverage to which PP 05 88 has been added, the added PIP limits apply as excess over any amounts recovered under the other policy.

 Tort Liability

 Owners, operators, and occupants of motor vehicles on which required no-fault coverage is in effect are exempt under the New York no-fault statute from tort liability for noneconomic loss except in the case of serious injury. “Serious injury” is defined by statute as an injury that results in death; dismemberment; significant disfigurement; fracture; permanent loss of a body organ, member, function, or system; limitation of use of a body organ, member, function, or system; or substantial disablement for at least ninety of the 180 days immediately following the injury.