OGC Opinion No. 06-02-08

The Office of General Counsel issued the following opinion on February 9, 2006, representing the position of the New York State Insurance Department.

Re: No-Fault Explanation of Benefits

Question Presented:

Must health care treatment provided to an eligible injured person under No-Fault last for a six month period in order to trigger an insurer's obligation to send an Explanation of Benefits ("EOB") statement to such person?


No. Pursuant to N.Y. Comp. Codes R. & Regs. tit 11, § 65-3.17(2002) (Department Regulation 68), which governs Explanation of Benefits statements under No-Fault, any benefits paid during the six month period after a motor vehicle accident, and any applicable six month period after that, triggers the insurer's obligation to issue an EOB statement, no matter how long the duration of treatment is.




Section 65-3.17 is the Explanation of Benefits provision in the No-Fault regulation and reads as follows:

At least for every six month period during which any benefits are paid, the insurer shall forward an Explanation of Benefits (EOB) to the eligible insured person and such person's attorney. The first six month period shall commence on the date of the accident and the EOB shall be mailed within 60 days of the conclusion of the period selected by the insurer. Such EOB shall include, at a minimum, the name of the payee, a description of the service or benefit claimed and the amount paid. It shall also include the Fraud Warning Statement prescribed on the Application for Motor Vehicle No-Fault Benefits (NYS Form N-F2) contained in Appendix 13 and the name, address and telephone number of the insurer representative to whom questions should be directed.

The regulation is very clear in that any benefit paid during at least the sixth month period after an accident, as well as in subsequent six month periods when benefits are paid, triggers the No-Fault insurer's obligation to send an EOB to the eligible injured person. An insurer can always choose to send out an EOB more frequently than every six months. The EOB statement must be mailed within 60 days after the conclusion of the benefit period.

With respect to whether or not health services must last for at least a six month period in order to require an EOB statement, there is nothing in the regulation that would support such an interpretation.

For further information please contact Supervising Attorney Lawrence M. Fuchsberg at the New York City Office.