NV PT Juris flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

PIP first-party no-fault coverage

Personal Injury Protection pays the insured's own medical, income continuation, essential services, and death benefits after an auto accident regardless of who caused it, subject to the policy's elected limits, deductible, and co-payment.

AICRA

The Automobile Insurance Cost Reduction Act of 1998, codified in N.J.S.A. 39:6A-1 et seq., which restructured New Jersey PIP limits, deductibles, the verbal threshold, and the tort option election system.

PIP follows the person

PIP coverage generally attaches to the insured person, covering the named insured and resident relatives in any vehicle and as pedestrians, rather than only while occupying the described auto.

PIP versus health insurance

PIP is primary over health insurance for auto injuries unless the insured validly elected the health care primary option, in which case the health plan pays first and PIP covers deductible, co-payment, and remainder.

Mandatory PIP inclusion

No private passenger auto liability policy may be issued or renewed in New Jersey without PIP coverage; the carrier must include it and disclose the elected limit and deductible on the declarations page.

Workers' compensation primacy

Where the injury arises out of employment, workers' compensation is the primary remedy and PIP is secondary or excluded to the extent of the comp obligation, preventing duplicate recovery.

Medical expense benefits

PIP medical benefits pay reasonable, necessary, and causally related treatment, testing, and equipment arising from the auto accident, up to the elected limit after deductible and co-payment.

Income continuation benefits

PIP pays 80% of lost gross income for disability caused by the accident, subject to a weekly statutory maximum and an aggregate per-accident cap, paid as wage loss accrues.

Essential services benefits

PIP reimburses up to $100 per day for reasonable and necessary household services the injured person can no longer perform, such as child care, housekeeping, and home maintenance, subject to the aggregate limit.

Death benefits

PIP provides a statutory death benefit, commonly $10,000, to the estate or surviving dependents when death results from the auto accident, in addition to income continuation for survivors.

Causation requirement

PIP benefits are payable only where the injury arises out of the ownership, maintenance, or use of an automobile; a carrier may deny benefits where that causal link is absent.

PIP medical expense limit

The dollar maximum the insured selects for PIP medical benefits, commonly ranging from $15,000 to $250,000; the chosen limit and its paired deductible appear on the declarations page.

PIP deductible

A fixed amount, commonly $250 to $2,500, deducted once per accident from medical expense benefits before PIP pays; it does not reduce income continuation, essential services, or death benefits.

PIP co-payment

Under the standard AICRA policy, a 20% co-payment applies to medical expense benefits above the deductible, capped at $5,000 per accident, unless the insured elected a different option.

Health care primary election

An option under which a qualifying health plan pays first for auto injuries and PIP pays the deductible, co-payment, and remaining balance up to the PIP limit, lowering premium.

Managed care PIP option

A lawfully elected PPO or HMO-style option that may require treatment through network providers, subject to statutory exceptions for emergency and out-of-network care.

Deductible disclosure rule

The deductible must be disclosed on the declarations page and validly elected; a carrier that fails to obtain a proper election or disclose the deductible may be barred from enforcing it.

Verbal threshold

The limitation on lawsuit option bars non-economic damages unless the injury is death, dismemberment, significant disfigurement, displaced fracture, loss of a fetus, or permanent injury.

Permanent injury standard

A verbal threshold category requiring objective medical evidence that the injury is permanent and causally related; subjective complaints alone do not satisfy the requirement.

Zero threshold option

The no-limitation-on-lawsuit tort option, purchased at higher premium, which permits recovery of non-economic damages for any injury caused by the accident without meeting the verbal threshold categories.

Tort option binding rules

The tort option selected for the host vehicle binds the named insured, resident relatives, and guest passengers; a pedestrian is bound by the policy of the striking vehicle.

Excess economic damages

Medical bills and lost wages exceeding PIP limits may be recovered in tort regardless of the tort option chosen, because the verbal threshold limits only non-economic damages.

PIP claim notice

The insured must submit a written PIP application with medical records and bills; the carrier must then pay or deny within the regulatory time frames or face interest and fee exposure.

Independent medical examination

A carrier-ordered examination or records review used to assess causation, reasonableness, and necessity of treatment; the insured must cooperate, and non-cooperation can support denial.

Usual customary reasonable reduction

A carrier may reduce an excessive provider bill to the usual, customary, and reasonable level or applicable fee schedule, with written notice and explanation to the provider.

PIP subrogation

The PIP carrier's right to recover benefits paid from the at-fault party or their liability carrier, enforced through statutory subrogation and lien provisions.

Written denial requirement

Every denial must be in writing, state the specific reason, and advise the insured or provider of appeal and arbitration rights; conclusory denials risk being found unfair claims practices.

Dispute Resolution Professional

The arbitrator who decides PIP disputes on medical necessity, causation, and charge reasonableness under N.J.A.C. 11:3-5, with awards binding subject to limited court review.

Arbitration filing deadline

A PIP arbitration demand must generally be filed within the applicable limitations period, commonly two years from service or denial; late filing can bar the claim.

Vacating an arbitration award

A court may vacate or modify a PIP arbitration award only on limited statutory grounds such as fraud, arbitrator misconduct, or exceeding authority; the merits are not re-litigated.

Insurance Fraud Prevention Act

N.J.S.A. 17:33A-1 et seq. prohibits knowingly false statements to obtain insurance benefits and authorizes civil penalties, treble damages, and criminal referral for violations.

OIFP reporting duty

Carriers must maintain a fraud detection program and refer suspected fraudulent claims to the Office of the Insurance Fraud Prosecutor while cooperating with law enforcement investigations.