No Fault (New York) vs Medical

Help please

FiL had a car accident in April (single vehicle)

Went to ER

No Fault Claim for medical was not filled out until October

He died ( not from accident)

SiL recieved letter that claim is denied. Haven’t seen it yet. She implied they objected to the charge amounts.

  1. I would think if that was the issue, they would go to the hospital

  2. if they decline is there any reason this wouldn’t be payable by his Medicare?

I’m very clueless about this. One possible reason that might apply in my own case: I have Medicare Advantage, not Medicare. So “in network” vs “out of network” is important for me. I know I have some coverage for out of network ER, but possibly less or no coverage for out of network ER if it was unreasonable to go to an ER. (Doesn’t sound likely that would apply after an auto accident, and I think I would have some coverage even if it were unreasonable to use the ER.)

A different reason that applied to me more than 5 years ago (and seems unlikely to apply in the FIL’s case): could the no-fault limit have been reached? (It was in my case, and I thought I was going to be burned to some extent, since some expenses that weren’t covered under normal medical were potentially covered under the no-fault medical. So I thought I was going to hit the no-fault limit, with some expenses that would have been covered under either, then have to pay some later ones not covered by regular medical. To my surprise, that didn’t happen. I’m still not sure why. Maybe some providers didn’t pursue it after no-fault didn’t pay.)

An insurer wants a reasonable time to investigate
the facts of the claim while the evidence is fresh.

Automobile No-Fault rules follow state laws.

NY No-Fault auto is primary over health insurance up to the No-Fault limit.

However, a claimant has 30 days from the accident to file a No-Fault claim,
or else the No-Fault insurer can deny the claim.

I believe health insurance rules are not as codified, but there are probably
time limits on filing a claim.

Either type of insurer should be made to explain specifically why a claim is denied.