NV PT Juris cheat sheet

PIP is first-party, no-fault coverage: the insured's own carrier pays medical expense, income continuation, essential services, and death benefits regardless of fault, subject to the policy's elected limits and deductibles.

Core statutes: N.J.S.A. 39:6A-1 to 39:6A-35 (Automobile Insurance Cost Reduction Act, AICRA, 1998) governs PIP, the verbal threshold, and tort options; N.J.S.A. 39:6A-4 sets the standard medical expense benefit framework.

Every private passenger auto liability policy issued in New Jersey must include PIP; a policy cannot be written or renewed without it, and PIP follows the insured person rather than the vehicle in most circumstances.

PIP covers the named insured, resident relatives, permissive operators and passengers, and pedestrians struck by the insured vehicle; occupants of the insured vehicle are covered even if not related to the named insured.

PIP is primary over health insurance for auto-related injury in New Jersey, but the insured may elect to coordinate PIP medical benefits with a health plan meeting statutory requirements (the 'health care primary' option).

PIP medical expense benefits have no fixed statutory dollar cap; the insured selects a limit at purchase (commonly $250,000), and coverage may not be less than the minimum required by statute and regulation.

AICRA created the option structure: insureds choose a tort option (limitation on lawsuit / verbal threshold or no limitation) and a PIP medical expense limit with an associated deductible.

PIP benefits are payable as expenses are incurred; the carrier must pay or deny within the statutory/regulatory time frames, and unpaid or denied amounts go to PIP arbitration (DRP) or Superior Court.

PIP does not cover workers' compensation injuries where workers' comp is the primary remedy; the auto carrier's obligation is secondary or excluded to the extent of the comp obligation.

Medical expense benefits cover reasonable, necessary, and causally related treatment, diagnostic testing, and durable medical equipment; treatment must fall within the statutory definition of medical expense benefits.

Income continuation benefits replace lost wages at 80% of the insured's lost gross income, subject to a statutory maximum per week and an aggregate dollar maximum per accident.

Income continuation requires proof of disability and lost earnings (typically employer or physician documentation); benefits are paid periodically as wage loss accrues, not as a lump sum at the outset.

Essential services benefits reimburse up to $100 per day for reasonable and necessary services the injured person can no longer perform (child care, housekeeping, home maintenance), subject to the policy's aggregate limit.

Death benefits provide a statutory death benefit (commonly $10,000) payable to the estate or surviving dependents where death results from the auto accident within the statutory period.

Income continuation and essential services are subject to a combined or separate aggregate maximum; the policy declarations control the elected amount, and the statutory default applies if no election was made.

PIP benefits extend to a surviving spouse and dependents for loss of the deceased insured's income contribution, consistent with the death benefit and income continuation provisions.

Medical expense benefits are payable to the provider or reimbursed to the insured; the carrier may not direct treatment to a network unless the policy lawfully includes a managed care option.

Causation is the threshold: the carrier may deny benefits where the injury did not arise out of the ownership, maintenance, or use of an automobile.

The insured selects a PIP medical expense limit at policy inception; common options run from $15,000 up to $250,000, and the deductible is tied to the limit selected.

Standard deductible options are $250, $500, $1,000, $2,000, and $2,500; the deductible applies once per accident to medical expense benefits, not per claim or per provider.

A higher deductible lowers premium; a $2,500 deductible with a $250,000 limit is a common cost-saving election and applies to the named insured and resident relatives.

Co-payment: AICRA's standard policy includes a 20% co-payment on medical expense benefits above the deductible, capped at $5,000 per accident, unless the insured elects a different option.

The deductible and co-payment do not apply to income continuation, essential services, or death benefits; they apply only to medical expense benefits.

The insured may elect 'health care primary' coordination, under which a qualifying health plan pays first and PIP pays the deductible, co-payment, and any remaining balance up to the PIP limit.

Managed care options (Preferred Provider Organization or Health Maintenance Organization style) may apply if lawfully elected; the carrier may then require treatment through network providers subject to statutory exceptions.

The deductible must be disclosed on the declarations page; a carrier's failure to obtain a valid election or to disclose the deductible can bar enforcement of the deductible against the insured.

Optional additional PIP benefits (e.g., higher income continuation limits, additional death benefits) may be purchased and must be shown on the declarations page.

The 'limitation on lawsuit' option (verbal threshold) bars recovery of non-economic damages unless the injury falls into one of six statutory categories: death, dismemberment, significant disfigurement or scarring, displaced fracture, loss of a fetus, or permanent injury.

'Permanent injury' requires objective medical evidence; subjective complaints alone do not satisfy the threshold, and the treating physician must certify the injury is permanent and causally related.

The six categories are exclusive under N.J.S.A. 39:6A-8(a); a plaintiff who cannot fit a category is limited to economic damages (PIP and excess economic loss).

The 'no limitation on lawsuit' (zero threshold) option permits recovery of non-economic damages for any injury caused by the accident, at a higher premium.

The tort option applies to the named insured and resident relatives; a guest passenger is bound by the host vehicle's tort option, and a pedestrian by the policy of the vehicle that struck them.

A lawsuit for non-economic damages must be filed within the statute of limitations (two years for personal injury in New Jersey) and must include the physician's certification of permanency.

Economic damages beyond PIP (excess medical bills, lost wages above PIP limits) may be recovered in tort regardless of the tort option selected.

The verbal threshold does not bar claims for property damage or for PIP benefits; it limits only non-economic damages in a third-party liability action.

A carrier must offer both tort options and document the insured's selection; a missing or invalid election can result in the default zero threshold applying.

The insured must submit a written notice of claim (the PIP application) and medical bills/records; the carrier must pay or deny within the time frames set by N.J.A.C. 11:3-25 and the Unfair Claims Settlement Practices regulations.

The carrier may request additional information, an independent medical examination (IME), or a records review; the insured must cooperate, and non-cooperation can support denial.

Payment is due for reasonable and necessary treatment; the carrier may reduce a bill to the usual, customary, and reasonable (UCR) level or to the fee schedule where applicable, with notice to the provider.

Coordination of benefits: PIP is generally primary over health insurance unless the insured elected health care primary; workers' compensation is primary over PIP for work-related injuries.

Subrogation: the PIP carrier may seek reimbursement from the at-fault party or their liability carrier for benefits paid, subject to the statutory subrogation and lien provisions.

The carrier must issue a written denial specifying the reason and the appeal/arbitration rights; a bare or conclusory denial is subject to challenge as an unfair claims practice.

Providers may bill the carrier directly and may seek payment from the insured only in limited circumstances; balance billing of PIP patients is restricted.

Interest may accrue on overdue PIP payments, and the carrier may be liable for counsel fees and costs where benefits were wrongfully withheld.

Records must be maintained to support each payment decision, including the medical records relied on and the fee analysis applied.

A denial must be in writing and state the specific reason (e.g., lack of causation, treatment not reasonable/necessary, policy limit exhausted, deductible/co-payment applied).

The insured or provider may challenge a denial through the carrier's internal appeal, then through PIP arbitration administered by the Dispute Resolution Professional (DRP) under N.J.A.C. 11:3-5.

PIP arbitration is binding on the parties for the amount in dispute; the arbitrator decides medical necessity, causation, and the reasonableness of charges, applying the statutory fee schedules.

A demand for arbitration must be filed within the statutory period (generally two years from the date of service or denial, subject to the applicable limitations period); late filing can bar the claim.

Arbitration costs are allocated by the arbitrator; the carrier bears costs where it acted unreasonably, and the arbitrator may award counsel fees in appropriate cases.

A party may seek to vacate or modify an arbitration award in Superior Court only on limited statutory grounds (e.g., fraud, misconduct, exceeding authority); the merits are not re-litigated.

The DRP process is separate from a tort action; a pending PIP arbitration does not toll the two-year statute of limitations for a third-party liability claim.

The carrier must comply with the arbitration award within the time set; failure to pay can lead to enforcement proceedings and additional interest or fees.

Exhaustion of the arbitration process is generally required before seeking court relief on a PIP benefit dispute, subject to statutory exceptions.

New Jersey's Insurance Fraud Prevention Act (N.J.S.A. 17:33A-1 et seq.) prohibits knowingly making false or misleading statements to obtain insurance benefits; violations carry civil penalties and criminal exposure.

The carrier must maintain a fraud prevention program, including detection, investigation, and referral of suspected fraudulent claims to the Office of the Insurance Fraud Prosecutor (OIFP).

Suspected fraud must be reported to the OIFP; the carrier may also refer to the National Insurance Crime Bureau and must cooperate with law enforcement investigations.

The carrier may suspend or deny benefits pending a fraud investigation where there is a reasonable basis, but must document the basis and follow the statutory notice requirements.

Material misrepresentation on an application (e.g., undisclosed household members, false garaging address) can void the policy or justify rescission, subject to the materiality and innocent insured rules.

Staged accidents, exaggerated injury claims, and provider billing schemes (upcoding, unbundling, phantom treatment) are common PIP fraud patterns the carrier must detect.

The carrier must maintain records of fraud referrals and investigations; regulators examine the fraud program during market conduct examinations.

Anti-fraud provisions apply to producers as well: a producer who knowingly submits or facilitates a false application or claim is subject to license discipline and criminal liability.

The Insurance Fraud Prevention Act authorizes civil actions by the carrier or the Commissioner and provides for treble damages and penalties in appropriate cases.

The New Jersey Department of Banking and Insurance (DOBI) licenses insurers, producers, and adjusters; a producer must hold the appropriate line of authority (property and casualty) to sell auto insurance.

Producers must complete continuing education (including ethics and flood/NFIP where applicable) and renew licenses on the statutory cycle; lapsed licenses bar solicitation and sale.

Insurers must file policy forms and rates with DOBI; rates must not be excessive, inadequate, or unfairly discriminatory, and deviations require approval.

Market conduct examinations review claims handling, underwriting, rating, producer conduct, and complaint records; adverse findings can lead to fines, restitution, and license action.

The carrier must maintain a complaint log and respond to DOBI inquiries within the required time; failure to respond is itself a violation.

Recordkeeping: policy, claims, and producer records must be retained for the statutory period and made available to examiners on request.

Producers owe a fiduciary duty for premiums collected, must remit promptly, and may not commingle client funds with personal or agency funds.

Advertising and solicitation must be accurate and not misleading; illustrations of savings or coverage must be supportable and consistent with filed forms.

Unauthorized insurer business (surplus lines without authority, unlicensed carriers) exposes the producer to discipline and the insured to no guaranty fund protection.

The Unfair Claims Settlement Practices Act (N.J.S.A. 17:29B-1 et seq.) and N.J.A.C. 11:2-17 prohibit misrepresenting policy provisions, failing to investigate promptly, and refusing to pay without a reasonable basis.

Specific prohibited practices include failing to acknowledge communications within a reasonable time, failing to adopt reasonable standards for prompt investigation, and offering substantially less than the amount owed.

The carrier must provide a written explanation for any reduction or denial and must not compel the insured to litigate to recover an undisputed amount.

Producers must act in the client's interest in placing coverage, disclose commissions and conflicts where required, and not bind coverage without authority.

A producer who knows the insured's coverage needs (e.g., PIP limits, tort option) must document the recommendation and the insured's election; failure to do so can create errors and omissions exposure.

The Consumer Fraud Act (N.J.S.A. 56:8-1 et seq.) can reach deceptive insurance sales and claims practices, with treble damages and attorney fees available to prevailing consumers.

The carrier and producer must protect confidential personal information (GLBA/privacy rules) and provide required privacy notices.

Complaints to DOBI are public records to the extent permitted; a pattern of complaints can trigger a market conduct examination and enforcement action.

Remedies for unfair claims practices include payment of benefits, interest, counsel fees, and regulatory penalties; bad-faith claims may support extra-contractual damages in appropriate cases.