N.J. Admin. Code § 11:3-28.7

Current through Register Vol. 56, No. 9, May 6, 2024

Section 11:3-28.7 - Reimbursement of excess medical expense benefits paid by insurers

(a) Insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefit claim payments as soon as practicable after the close of the quarter for which reimbursement is sought for claim payments of $ 20,000 or more. For claim payments of less than $ 20,000, insurers shall submit to the Fund itemized accounts with supporting documentation of excess medical expense benefits either quarterly or at the close of the calendar year in which such expenses are incurred. Insurers shall not be reimbursed for interest, attorney fees or punitive damages.

1. Regardless of the size of a claim payment for excess medical expense benefits, an insurer shall submit to the Fund a request for reimbursement within a period of two years from the date of payment by the insurer of the excess medical expense benefit for which reimbursement is sought.

2. Failure to comply with the requirements set forth in (a)1 above shall result in a denial by the Fund of the reimbursement request which was omitted from the quarterly submission.

(b) The Fund shall not reimburse an insurer for excess medical expense benefits if it is determined that there are multiple insurance policies applicable to a claim unless an insurer has expended medical benefits in an amount exceeding $ 75,000 on account of personal injury to any one person in any one accident. Where there are two or more different primary insurers liable, the Fund shall not reimburse such an insurer for excess medical expense benefits unless each primary insurer has expended medical benefits in an amount exceeding $ 75,000 on account of personal injury to any one person in any one accident.

(c) Where the Fund has reimbursed an insurer for excess medical expense benefits and thereafter determines that there were or are multiple insurance policies applicable to the underlying claim, the insurer shall return all moneys paid from the Fund. The insurer(s) shall apportion the medical benefits payment and make individual application to the Fund where the potential exposure to the insurer(s) exceeds $ 75,000 on account of personal injury to any one person in any one accident.

(d) Whenever an insurer recovers amounts expended by it for medical benefits, it shall not be reimbursed for excess medical expense benefits unless it has fully repaid the amount previously reimbursed by the Fund.

N.J. Admin. Code § 11:3-28.7

Recodified from 11:3-28.6 and amended by R.1993 d.583, effective 11/15/1993.
See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a).
Amended by R.2006 d.243, effective 7/3/2006.
See: 37 N.J.R. 4162(a), 38 N.J.R. 2828(c).
Rewrote (a).
Amended by R.2007 d.61, effective 2/20/2007.
See: 38 N.J.R. 4391(a), 39 N.J.R. 653(a).
Rewrote (a)1.