Create Auto Insurance Advocate Office

Section 1. Subsections (a), (b) and (c) of section 5106 of the insurance law, subsection (b) as amended by chapter 452 of the laws of 2005, are amended to read as follows:

(a) Payments of first party benefits and additional first party benefits shall be made as the loss is incurred. Such benefits are overdue if not paid within thirty days after the claimant supplies proof of the fact and amount of loss sustained. If proof is not supplied as to the entire claim, the amount which is supported by proof is overdue if not paid within thirty days after such proof is supplied. All overdue payments shall bear interest at the rate of two percent per month. If a valid claim or portion was overdue, the claimant shall also be entitled to recover [his attorney's] a reasonable attorney fee, for services necessarily performed in connection with securing payment of the overdue claim, subject to limitations promulgated by the superintendent in regulations.

(b) Every claimant shall have the option of designating the name and address to which the insurer will be required to send duplicate copies of all requests for information and examinations.

(c)(1) Every insurer shall provide a claimant with the option of submitting any dispute involving the insurer's liability to pay first party benefits, or additional first party benefits, the amount thereof or any other matter which may arise pursuant to subsection (a) of this section to arbitration pursuant to simplified procedures to be promulgated or approved by the superintendent. Such simplified procedures shall:

EXPLANATION--Matter in italics (underscored) is new; matter in brackets

[ ] is old law to be omitted.

LBD11045-01-7

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(i) permit a claimant to group disputes arising from the same occurrence with a single insurer based on common questions of law and fact;

(ii) permit either the claimant or the insurer, at their own expense, to record or transcribe all proceedings related to the arbitration demand;

(iii) include an expedited eligibility hearing option, when required, to designate the insurer for first party benefits pursuant to subsection (d) of this section. The expedited eligibility hearing option shall be a forum for eligibility disputes only, and shall not include the submission of any particular bill, payment or claim for any specific benefit for adjudication, nor shall it consider any other defense to payment. [(c)] The expedited eligibility hearing option shall also be available to promptly adjudicate all disputes related to document requests and examinations under oath of a claimant health service provider regarding the provider's ineligibility for reimbursement due to the alleged failure to meet any applicable New York state or local licensing requirement necessary to perform such service in New York, or meet any applicable licensing requirement necessary to perform such service in any other state where such service is performed. The timely filing of the request for expedited eligibility hearing shall toll the time to comply until the time set forth in the arbitrator's decision.

(2) The commencement of a court proceeding or the submission of a dispute to arbitration shall not preclude a claimant from electing to submit other disputes arising from the same occurrence to the alternate forum. Arbitrators are required to follow and apply substantive law. An award by an arbitrator shall be binding except where vacated or modified by a master arbitrator in accordance with simplified procedures to be promulgated or approved by the superintendent. The grounds for vacating or modifying an arbitrator's award by a master arbitrator shall not be limited to those grounds for review set forth in article seventy-five of the civil practice law and rules and shall include factual, legal and procedural errors. The award of a master arbitrator shall be binding except for the grounds for review set forth in article seventy-five of the civil practice law and rules[, and provided further that where the amount of such master arbitrator's award is five thousand dollars or greater, exclusive of interest and attorney's fees, the insurer or the claimant may institute a court action to adjudicate the dispute de novo].

(3) With respect to an action for serious personal injury permissible under section five thousand one hundred four of this article, the award or decision of an arbitrator or master arbitrator rendered pursuant to a no-fault proceeding shall not constitute a collateral estoppel of the issues arbitrated, but such an award or decision may be admissible as relevant evidence by a party to an action.

§ 2. Section 5102 of the insurance law is amended by adding a new subsection (n) to read as follows:

(n) "Provider of health services" for purposes of this article, means an individual or entity who or that renders or has rendered health services, or who provides for remuneration an opinion to an insurer or an entity contracted by an insurer regarding either (i) whether a health service was medically necessary, or (ii) based upon an examination of the claimant, the need for any health service.

§ 3. Section 5109 of the insurance law, as added by chapter 423 of the laws of 2005, is amended to read as follows:

§ 5109. Unauthorized providers of health services. (a) The superintendent, in consultation with the commissioner of health and the commis-

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sioner of education, shall by regulation, promulgate standards and procedures for investigating and suspending or removing the authorization for providers of health services to demand or request payment for health services [as specified in paragraph one of subsection (a) of section five thousand one hundred two of] under this article upon findings reached after investigation pursuant to this section. Such regulations shall ensure the same or greater due process provisions, including notice and opportunity to be heard, as those afforded physicians investigated under article two of the workers' compensation law and shall include provision for notice to all providers of health services of the provisions of this section and regulations promulgated thereunder at least ninety days in advance of the effective date of such regulations. As used in this section, "health services" means services, supplies, therapies, or other treatments as specified in subparagraph (i), (ii), or (iv) of paragraph one of subsection (a) of section five thousand one hundred two of this article or an opinion rendered to an insurer or an entity contracted by an insurer regarding either (i) whether such services, supplies, therapies, or treatments were medically necessary, or (ii) based upon an examination of the claimant, the need for any such service, supply, therapy, or treatment.

(b) [The commissioner of health and the commissioner of education shall provide a list of the names of all providers of health services who the commissioner of health and the commissioner of education shall deem, after reasonable investigation, not authorized to demand or request any payment for medical services in connection with any claim under this article because such provider of health services] The superintendent, in consultation with the commissioner of health and the commissioner of education, may prohibit a provider of health services from demanding or requesting payment for health services rendered under this article, for a period specified by the superintendent, if the superintendent determines that the provider of health services:

(1) has admitted to or been found guilty of professional or other misconduct or incompetency in connection with [medical] health services rendered under this article; or

(2) has exceeded the limits of his or her professional competence in rendering medical care under this article, as determined by the appropriate supervising or licensing agency, or has knowingly made a false statement or representation as to a material fact in any medical report made, or document submitted, in connection with any claim under this article; or

(3) solicited, or has employed another to solicit for [himself or herself] the provider of health services or for another, professional treatment, examination or care of an injured person in connection with any claim under this article; or

(4) has refused to appear before, or to answer upon request of, the commissioner of health, the superintendent, or any duly authorized officer of the state, any legal question, or to produce any relevant information concerning [his or her] the conduct of the provider of health services in connection with [rendering medical services] health services rendered under this article; [or]

(5) has engaged in [patterns] a pattern of billing for health services which were not provided;

(6) knowingly utilized unlicensed persons to render health services under this article, when only a person licensed in this state may render the health services;

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(7) knowingly utilized licensed persons to render health services beyond the authorized scope of the person's license;

(8) directly or indirectly unlawfully ceded ownership or control of a business entity authorized to provide professional health services in this state, including a professional service corporation, professional limited liability company, or registered limited liability partnership, to a person not licensed to render the health services which the entity is legally authorized to provide, except where the unlicensed person's ownership or control is otherwise permitted by law;

(9) has engaged in a pattern of recommending against reimbursement when such recommendation is not supported by clearly established standards in the professional community;

(10) has submitted an examination report that contains material factual misrepresentations or professional conclusions that are not supported by clearly established standards in the professional community;

(11) consistently delivered unnecessary health services without reasonable medical justification as determined by the superintendent in consultation with the department of health and the state education department taking into consideration the overall health of the patient and issues of palliative care; or

(12) has violated any provision of this article or regulations promulgated thereunder.

(c) Providers of health services shall refrain from subsequently treating for remuneration, as a private patient, any person seeking medical treatment under this article if such provider pursuant to this section has been prohibited from demanding or requesting any payment for [medical] health services under this article. An injured claimant so treated or examined may raise this as a defense in any action by such provider for payment for treatment rendered at any time after such provider has been prohibited from demanding or requesting payment for [medical] health services in connection with any claim under this article. Providers of health services who have been prohibited from demanding or requesting any payment for health services under this article shall also refrain from subsequently providing for remuneration an opinion to an insurer or an entity contracted by an insurer regarding either (i) whether a health service was medically necessary, or (ii) based upon an examination of the claimant, the need for any health service.

(d) The [commissioner of health and the commissioner of education] superintendent shall maintain and regularly update a database containing a list of providers of health services prohibited by this section from demanding or requesting any payment for health services [connected to a claim] rendered under this article and shall make such information available to the public by means of a website and by a toll free number.

(e) Nothing in this section shall be construed as limiting in any respect the powers and duties of the commissioner of health, commissioner of education or the superintendent to investigate instances of misconduct by a [health care] provider [and, after a hearing and upon written notice to the provider, to temporarily prohibit a provider of health services under such investigation from demanding or requesting any payment for medical services under this article for up to ninety days from the date of such notice] of health services and take appropriate action pursuant to any other provision of law. A determination pursuant to subsection (b) of this section shall not be binding upon the commissioner of health or commissioner of education in a professional discipline proceeding relating to the same conduct but may be admitted as evidence.

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§ 4. Paragraph 1 of subsection (a) of section 308 of the insurance law, as amended by chapter 499 of the laws of 2009, is amended to read as follows: