NJ Auto Policy Does Not Cover PIP for Insured as a Pedestrian Struck in New York
In the Matter of the Arbitration between: St. Lukes Roosevelt Hospital Center and New Jersey Manufacturers Insurance Co
Edited by Lawrence N. Rogak
The claimant had a New Jersey auto policy in which he elected to have his own health insurance be primary for his medical expenses. The claimant was a pedestrian in New York and was struck by a taxi. The arbitrator held that the claimant was not entitled to PIP benefits from his NJ policy and that AAA had no jurisdiction over the PIP claim because none of the insured’s NJ vehicles were involved in the NY accident.—LNR
?The issue in dispute is whether Respondent, a New Jersey Insurance Company, is bound by a contractual obligation to cover Assignor’s no-fault benefits as a result of injuries Assignor sustained when struck while a pedestrian by a taxi cab in the State of New York.
This claim arises out of injuries Assignor sustained in a motor vehicle accident on January 4, 2016 for which Applicant provided evaluation immediately thereafter. Upon receipt of Applicant’s bill totaling $7,940.60, Respondent duly denied payment predicated upon jurisdiction conflicts and Assignor’s obligation contained within the underlying insurance policy to seek first party benefits from his private medical carrier prior to seeking direct payment from Respondent.
As such, this Arbitrator, after a thorough review of the evidence adopts Respondent’s factual and legal analysis, in sum and substance, as follows:
“This is a claim by Applicant against Respondent to recover New York no-fault benefits. This claim, however, arises under a New Jersey auto policy, containing a New Jersey endorsement, issued by a New Jersey insurance company, and delivered to a New Jersey resident. While the New Jersey insured was in New York at the time of the accident, he was a pedestrian, not a motorist, and none of the vehicles covered by the out-of-state policy were involved in the New York accident. Both the policy and the New York no-fault statute require that a vehicle covered by the out-of-state policy be used or operated in New York at the time of the accident before New York no-fault coverage may be imposed on the out-of-state carrier.”
At the time the coverage was purchased, Assignor exercised his right under New Jersey law to make their health insurance primary to the PIP coverage.
On January 4, 2016, Assignor notified Respondent that he was a pedestrian in New York when he was struck by a New York taxi cab.
Respondent confirmed the facts surrounding the incident including verification via police information, the offending vehicle’s insurance coverage and outreach to Applicant’s facility inquiring as to why, pursuant to the aforesaid conditions of the herein insurance policy, payment was sought for Assignor’s medical treatment, but to no avail.
As such, Respondent seeks a decision in its favor for the following reasons: (1) since Assignor was a pedestrian in New York when struck by a New York taxi cab, there is no contractual or statutory basis for Applicant to recover New York no-fault benefit under Respondent’s New Jersey auto policy; (2) since any claim Respondent may have for no-fault benefits under Respondent’s auto policy is governed by the law of New Jersey (not New York), the AAA New York Insurance Case Management Center lacks jurisdiction over the subject matter of such a New Jersey no-fault dispute; and, (3) Respondent requires that New Jersey no-fault disputes be arbitrated in New Jersey and has not consented to arbitrate New Jersey no-fault dispute in New York.
Applicant relied on the Court’s holding in the Matter of American Insurance Co. v Nova Acupuncture PC, 137 A.D. 1270 (2016), where, in sum, when presented with a similar but not an identical fact pattern regarding an out-of-state insurance carrier doing business in New York opined, “the fact that the policies do not contain any agreement to arbitrate disputes involving the payment of first party benefits does not preclude the respondents from exercising their option to arbitrate the underlying dispute in this proceeding…here, it is undisputed that the respondents exercised their option to arbitrate the dispute over the payment of first-party benefits. It is further undisputed that Respondent is not licensed or authorize to transact business in the State. Nonetheless, Respondent policies may be deemed to satisfy New York’s financial security requirements and to provide for the payment of first-party benefits, which necessarily includes affording claimants the option to arbitrate disputes involving first-party benefits.”
Upon due consideration, a thorough review of the record and position statements presented during oral argument, I am confined to rule in Respondent’s favor.
The record is devoid of any indication that Applicant, an Assignee of an injured pedestrian, proffered direct documentation which, even remotely, would trigger this Arbitrator’s jurisdiction over the claim as presented. Of significance, Assignor clearly chose to purchase an insurance policy wherein his private health insurer would be the primary source of coverage in the event of injury from a covered automobile accident yet as duly argued by Respondent such linkage was not provided by Applicant for this claim. See, Respondent’s exhibit Insurance Policy, page 38. Furthermore, in this instance, Applicant did not credibly refute Respondent’s assertion that it is not subject to the jurisdiction of the New York No-Fault forum.
Accordingly, Applicant’s claim is denied.
AAA Case No. 17-16-1042-5603
Ellen Cutler-Igoe, arbitrator
Award date: 05/10/2018
