After a car accident in New York, your no-fault Personal Injury Protection (PIP) insurance provides up to $50,000 for medical expenses, lost wages, and other out-of-pocket costs. But what happens when your injuries require treatment that exceeds this limit? Many accident victims wonder whether they’re required to use their private health insurance once PIP benefits are exhausted—and how this affects their ability to recover compensation.
The short answer is yes, you will likely need to use your health insurance for ongoing medical care. However, understanding how this works—and how it affects your potential lawsuit—is essential for protecting your rights.
New York’s no-fault insurance law requires all motor vehicle insurance policies to include a minimum of $50,000 in PIP coverage. This coverage pays for reasonable and necessary medical expenses, 80% of lost earnings up to $2,000 per month for up to three years, up to $25 per day for other reasonable expenses like household help, and a death benefit of $2,000.
While $50,000 may seem like a significant amount, serious injuries can quickly exhaust these benefits. Extended hospital stays, surgeries, physical therapy, and ongoing treatment for conditions like traumatic brain injuries or spinal cord damage can easily surpass this threshold within weeks or months of an accident.
Once your PIP coverage is exhausted, you are responsible for any continuing medical expenses. At this point, you have several options for covering ongoing treatment. Your private health insurance, if you have it, becomes the primary payer for accident-related medical care after PIP benefits are depleted. Medicare or Medicaid may provide coverage if you qualify for these government programs. Some accident victims choose to pay out-of-pocket and seek reimbursement through a lawsuit against the at-fault driver, though this carries significant financial risk. Medical providers may agree to treat you on a lien basis, meaning they wait for payment until your case settles, but not all providers offer this arrangement.
For most people, using private health insurance is the most practical solution for continuing medical care.
When you use your health insurance for car accident injuries, several important factors come into play.
Subrogation rights: Most health insurance policies include subrogation clauses that give the insurance company the right to be reimbursed from any settlement or verdict you receive. This means if you recover money from the at-fault driver, your health insurer may be entitled to recover what they paid for your accident-related medical care.
Network restrictions: You may need to switch to providers within your health insurance network, which could mean changing doctors or treatment facilities you’ve been working with since your accident.
Deductibles and copays: Unlike PIP coverage, which typically pays 100% of covered expenses, health insurance usually requires you to pay deductibles, copayments, and coinsurance. These out-of-pocket costs can be recovered as part of your personal injury claim.
Pre-authorization requirements: Some treatments that were approved under PIP may require pre-authorization under your health insurance plan, potentially causing delays in care.
If your injuries meet New York’s “serious injury” threshold and you’re pursuing a lawsuit against the at-fault driver, using health insurance can actually work in your favor in several ways.
First, it ensures you continue receiving necessary medical treatment without interruption. Gaps in treatment can hurt your case by suggesting your injuries aren’t as serious as claimed. Second, documented ongoing medical care helps establish the full extent of your injuries and their impact on your life.
In your lawsuit, you can seek compensation for all accident-related medical expenses, including what your health insurance paid and what you paid out-of-pocket. New York follows the “collateral source rule,” which generally prevents defendants from reducing damages based on insurance payments you received. However, health insurance liens must typically be addressed from any settlement or verdict.
Accident victims without health insurance face more challenging situations once PIP benefits run out. Options may include applying for Medicaid if you meet income requirements, negotiating directly with medical providers for reduced rates or payment plans, finding providers willing to treat you on a medical lien basis, or accessing community health centers that offer sliding-scale fees.
An experienced personal injury attorney can help you explore options for continuing care and may be able to connect you with medical providers who work with accident victims awaiting settlement.
If you’re approaching the $50,000 PIP limit, taking proactive steps can help ensure continuity of care and protect your legal rights. Monitor your PIP benefits closely and request regular statements from your no-fault insurer showing remaining coverage. Notify your health insurance company about the accident—most policies require you to report accidents even if you’re not immediately filing claims. Review your health insurance policy to understand coverage, network requirements, and any accident-related provisions. Keep detailed records of all medical treatment, expenses, and communications with insurers. Consult with a personal injury attorney who can advise you on managing the transition from PIP to health insurance coverage while protecting your claim.
Exhausting your PIP coverage is often a sign that you’ve suffered significant injuries that may entitle you to additional compensation beyond no-fault benefits. Navigating the transition from PIP to health insurance while pursuing a personal injury claim requires careful attention to deadlines, documentation, and insurance requirements.
At Palermo Law, we help car accident victims throughout Suffolk County and Long Island understand their options and fight for the full compensation they deserve. If your PIP benefits are running out or have been exhausted, we can evaluate whether you have a valid claim against the at-fault driver and help you understand how to protect your rights while continuing your medical treatment.
Contact us today for a free consultation. We’ll review your situation, explain your legal options, and help you make informed decisions about your care and your case.