N.J. Admin. Code § 11:3-28.13

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:3-28.13 - Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims

(a) The Fund shall reimburse insurers for paid medical expense benefit claims if an insurer demonstrates that it has diligently pursued all potentially responsible tortfeasors within the time prescribed at 39:6A-9.1, or any other applicable limitation period.

1. An insurer shall demonstrate, in accordance with (c) below, that it has diligently pursued any potentially responsible tortfeasor to obtain reimbursement of PIP medical expense benefit claim payments made by the insurer from the Fund.

2. Where the insurer has failed to diligently pursue any potentially responsible tortfeasor as set forth in (c) below, the Fund shall be entitled to discontinue reimbursements on that claim. The Fund shall also be entitled to recover from the insurer any reimbursement payments already made to the insurer on that claim, after notice and opportunity for a hearing in accordance with the Administrative Procedure Act, 52:14B-1 et seq. and Uniform Administrative Procedure Rules, N.J.A.C. 1:1.

3. An insurer shall obtain prior approval from the Fund before settling or compromising a claim against a potentially responsible tortfeasor or a tortfeasor.

(b) Any and all expenses and fees incurred by the insurer as a result of the pursuit of a potentially responsible tortfeasor, shall be borne by the insurer.

(c) For purposes of this section, "diligently pursue" means that the insurer has either prosecuted or is prosecuting an action, including by agreement or arbitration, in matters subject to 39:6A-9.1, against all potentially responsible tortfeasors, or determined not to do so after:

1. Examining or reviewing the following documents, where applicable:

i. Police accident reports, including fatal accident reports and supplemental reports;

ii. Statements of the parties involved;

iii. Witness statements;

iv. Central Index Bureau return results;

v. Information about the assets of uninsured tortfeasors;

vi. Scene photographs and diagrams;

vii. Reports of blood alcohol content;

viii. Relevant court records and information on any related suits, arbitrations, settlements or judgments, either within or outside the State, including, but not limited to:

(1) Pleadings;

(2) Transcripts of depositions and other related discovery materials; and

(3) Amounts of settlements or judgments; and

ix. Information about the amount of any potentially responsible tortfeasor's insurance liability limits, including, but not limited to, umbrella and excess insurance policies; and

2. Considering the following factors in determining whether to prosecute an action against potentially responsible tortfeasors:

i. The liability of the parties involved;

ii. Relevant law regarding right of recovery actions; and

iii. The basis for denial of coverage by the insurer of the potentially responsible tortfeasor.

(d) Insurers shall file a certification, in the form of Appendix C incorporated herein by reference, that they have diligently pursued recovery of medical expense benefits, and that the insurer has not received from any source reimbursement, contribution, or indemnification of the excess medical benefits paid by the insurer for which reimbursement from the Fund is sought. This certification shall be signed by an officer of the insurer or other person authorized to sign the certification on behalf of the insurer, and shall be filed no later than two years from the date of the accident, prior to expiration of any applicable statute of limitations, or at the time filing for reimbursement is made, whichever occurs first. Failure to file the certification shall result in denial of reimbursement to the insurer by the Fund.

(e) All recovery amounts obtained or that should have been obtained from the tortfeasor will be deducted from the reimbursement claim.

N.J. Admin. Code § 11:3-28.13

New Rule, R.1993 d.583, effective 11/15/1993.
See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a).
Amended by R.2001 d.151, effective 5/7/2001.
See: 32 N.J.R. 3714(a), 33 N.J.R. 1389(a).
Rewrote (a); in (b), deleted "right of recovery against a" and inserted "potentially responsible" preceding "tortfeasor"; added (c) and (d).
Amended by R.2006 d.243, effective 7/3/2006.
See: 37 N.J.R. 4162(a), 38 N.J.R. 2828(c).
Added (e).