SUBCHAPTER 26. UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT
11:3-26.1 Claim information
(a) Notice of intention to make a claim under N.J.S.A. 39:6-65 shall contain the following information:
1. The claimant's name, address, date of birth and social security number;
2. The time, date, location, municipality and county in which the loss occurred;
3. The identity of the operators and vehicles involved in the accident, including the name and address of the owner and operator and the license plate number of the vehicle;
4. Such witnesses to said accident as are then known;
5. A short description of the accident, including the claimant's role or position therein;
6. A description of the injuries then known, and attached thereto a medical certificate if then available. In any event the medical certificate shall be filed as soon as available;
7. A description of the damage sustained to property, and attached thereto an estimate of the cost of repairs if then available; and
8. The policy number of any insurance applicable to the accident, including the name and address of all insurance companies involved.
11:3-26.2 Claim filing; form
(a) A Notice of Intention to make Claim under N.J.S.A. 39:6-65 may be filed on form UCJF #72 of the Unsatisfied Claim and Judgment Fund Board designated as a "Notice of Intention to Make Claim", incorporated herein by reference as Appendix A.
(b) A written notice to the Board in any other form that contains the information required by this section shall be acceptable.
(c) A notice of intention to make a claim that does not contain the items identified in N.J.A.C. 11:3-26.1(a) 1 through 8 shall be returned to the sender and deemed to be not filed with the Unsatisfied Claim and Judgment Fund (UCJF) for the purpose of complying with N.J.S.A. 39:6-65 and shall not toll the statute of limitations.
SUBCHAPTER 26. UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT
SUBCHAPTER 27. UNSATISFIED CLAIM AND JUDGMENT FUND BOARD
11:3-27.1 Uninsured's current financial status
(a) Upon review of a case by the Unsatisfied Claim and Judgment Fund Board, if the Board does not have sufficient current information to determine whether or not the uninsured's installment payment is reasonable, a request will be addressed to the uninsured asking for a statement of current financial status.
(b) If the uninsured fails to furnish a completed statement of current financial status within a time period to be established by the executive director, the Unsatisfied Claim and Judgment Fund Board will request the Director of Motor Vehicles to suspend the license and all registrations of the uninsured pursuant to N.J.S.A. 39:5-30 and 39:5-87, for failure to furnish this information.
SUBCHAPTER 28. UNSATISFIED CLAIM AND JUDGMENT FUND'S REIMBURSEMENT OF EXCESS
MEDICAL EXPENSE BENEFITS PAID BY INSURERS
11:3-28.1 Purpose and scope
(a) The purpose of this subchapter is to establish procedures to ensure that only appropriate, reimburseable claims are submitted to the Fund by insurers by requiring investigation of the medical necessity for certain claims; requiring the audit of claims of $10,000 or more submitted by licensed providers of health care services or claims of $25,000 or more by health care facilities; and requiring prior approval of claims for alterations to vehicles and residences. This subchapter also requires insurers to pursue the proper, alternative sources for reimbursement where such other sources of funds are available.
(b) This subchapter applies to all insurers authorized in this State to write the kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1.
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise.
"Board" means the Unsatisfied Claim and Judgment Fund Board created in accordance with N.J.S.A. 39:6-64.
"Diagnosis related groups" or "DRG" means a patient classification scheme in which cases are grouped by shared characteristics of principal diagnosis, secondary diagnosis, age, surgical procedure, and other complications. Each DRG exhibits a consistent amount of resource consumption as measured by some unit (for example, length of stay or dollars).
"Excess medical expenses benefits" means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a, 39:6A-4.3, or 39:6A-3.1 that are in excess of $75,000 resulting from personal injury to any one person in any one accident.
"Fund" means the Unsatisfied Claim and Judgment Fund established pursuant to N.J.S.A. 39:6-61 et seq.
"Health care facility" means a health care provider that is a facility or institution, whether public or private, engaged principally in providing services for diagnosis of treatment of pain, injury, deformity or physical condition, including, but not limited to, a general hospital, special hospital, public health center, diagnostic center, treatment center, rehabilitation center, extended care facility, skilled nursing home, nursing home, intermediate care facility, outpatient clinic, dispensary or residential health care facility.
"Health care provider" or "provider" means those persons licensed or certified to perform health care treatment or services compensable as medical expenses and shall include, but not be limited to:
1. A hospital or health care facility which is maintained by a state or any of its political subdivisions;
2. A hospital or health care facility licensed by the Department of Health and Senior Services;
3. Other hospitals or health care facilities designated by the Department of Health and Senior Services to provide health care services, or other facilities, including facilities for radiology and diagnostic testing, freestanding emergency clinics or offices, and private treatment centers;
4. A nonprofit voluntary visiting nurse organization providing health care services other than in a hospital;
5. Hospitals or other health care facilities or treatment centers located in other states or nations;
6. Physicians licensed to practice medicine and surgery;
7. Licensed chiropractors;
8. Licensed dentists;
9. Licensed optometrists;
10. Licensed pharmacists;
11. Licensed chiropodists (podiatrists);
12. Registered bio-analytical laboratories;
13. Licensed psychologists;
14. Licensed physical therapists;
15. Certified nurse-midwives;
16. Certified nurse-practitioners/clinical nurse-specialists;
17. Licensed health maintenance organizations;
18. Licensed orthotists and prosthetists;
19. Licensed professional nurses;
20. Licensed occupational therapists;
21. Licensed speech-language pathologists;
22. Licensed audiologists;
23. Licensed physician assistants;
24. Licensed physical therapists assistants;
25. Licensed occupational therapy assistants; and
26. Providers of other health care services or supplies, including durable medical goods.
"Health care service" means the preadmission, outpatient, inpatient and postdischarge care provided in or by a health care facility, and such other items or services as are necessary for such care, which are provided by or under the supervision of a physician for the purpose of diagnosis or treatment of pain, injury, disability, deformity or physical condition, including, but not limited to, nursing service, home care nursing and other paramedical service, ambulance service, service provided by an intern, resident in training or physician whose compensation is provided through agreement with a health care facility, laboratory service, medical social service, drugs, biologicals, supplies, appliances, equipment, bed and board.
"Insurer" means any person authorized or admitted in this State to write the kinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1, pursuant to N.J.S.A. 17:17-1 et seq. or 17:32-1 et seq., as applicable. "Insurer" shall not include a surplus lines insurer eligible to write business pursuant to N.J.S.A. 17:22-6.40 et seq.
"Licensed nursing personnel" or "licensed nurse" means a nurse licensed by the New Jersey State Board of Nursing or the equivalent from another jurisdiction.
"Medical expense benefits" means medical expense benefits paid in accordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 and N.J.A.C. 11:3-4.
"Medically necessary" is as defined in N.J.A.C. 11:3-4.2.
"Per diem" means a daily fixed charge which includes room and board and other fees for services and supplies.
"PIP coverage" means personal injury protection coverage as described in N.J.S.A. 39:6A-4 or 39:6A-3.1.
"Person" means any individual, association, company, corporation, insurer, joint stock company, organization, partnership, society, syndicate, trust, any combination of the foregoing acting in concert or any other entity.
"Pre-screen" means an off-site review of the billings from a health care facility to determine whether the care given and amounts charged are appropriate.
"Provider" means any person that furnishes services or equipment for medical expense benefits for which payment is required to be made under PIP coverage in automobile insurance policies, but does not include health care facilities.
"Reimbursement" refers to reimbursement to insurers by the Fund as provided at N.J.S.A. 39:6-73.1.
"Uninsured motorist claims" means claims submitted against operators of uninsured vehicles and hit and run claims submitted pursuant to N.J.S.A. 39:6-61.
11:3-28.3 Report of claims when the carrier has paid at least $50,000 for medical expense benefits
In cases where the potential exposure to the automobile liability insurer exceeds $75,000, the insurer shall report on UCJF Form 1(321) (incorporated herein by reference as Form 1 in Appendix A) whenever medical expense benefits in a total amount of $50,000 have been paid on account of personal injury to any one person in any one accident.
11:3-28.4 Notice of change in the amount of reserves
Whenever an automobile liability insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount of $50,000, said insurer shall notify the Fund of any changes in the amount of reserves established for payment of the claim or closing of the file.
11:3-28.5 Supplemental forms to be submitted to the Fund
(a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Appendix A), shall be filed with the Fund within 90 days after an automobile insurer has paid medical expense benefits on account of personal injury to any one person in any one accident in a total amount in excess of $75,000. Such form together with UCJF Form 3(323) (incorporated herein by reference as Form 3 in Appendix A) shall be filed each quarter thereafter that the insurer seeks reimbursement.
(b) Any office of an insurer seeking reimbursement of funds from the UCJF for personal injury protection medical expense must also complete and file with the UCJF a New Jersey Information Questionnaire, UCJF Form 4(W-9) (incorporated herein by reference as Form 4 in Appendix A).
11:3-28.6 Insurer's continuing obligation to investigate claims
(a) An automobile liability insurer shall be required to discharge its duty of investigating claims where the potential exposure to the insurer exceeds $75,000. Said insurer's duty and obligation with regard to claim handling shall exist and continue to exist notwithstanding this rule. The Executive Director may direct such investigations as often as he or she deems necessary. All expenses relating to the investigation of claims, including expenses for medical examinations, file maintenance and cost containment measures, are the responsibility of the automobile liability insurer.
(b) The failure to properly discharge the duty of investigating a claim may result in the imposition of a penalty, to be determined by the UCJF Board of Directors, against the insurer's request for reimbursement.
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. The Fund shall reimburse automobile liability insurers for excess medical expense benefits on a quarterly basis. Insurers shall not be reimbursed for interest, attorney fees or punitive damages.
1. For a period of one year from the date of payment of a claim for excess medical expense benefits by an insurer, the insurer may submit to the Fund a request for reimbursement of a claim which was not included in the insurer's quarterly submission. The insurer shall include with its request, specific documentation to identify the subject payment.
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.
Upon request of the Fund, the insurer(s) shall present for audit at the direction of the Executive Director at a New Jersey location all policy and claim records on which notice of potential for payment of excess medical expense benefits have been submitted.
11:3-28.9 Reporting of losses for personal injury protection payments in excess of $75,000
(a) For purposes of completing page 14, Exhibit of Premiums and Losses, of the annual statement filed pursuant to N.J.S.A. 17:23-1, the insurer shall include the total amount of losses for private passenger automobile and commercial automobile personal injury protection payments (lines 19.1 and 19.3), including those in excess of $75,000. Insurers shall also provide a footnote on page 14 that indicates the amount of losses reported, excluding losses from payments of private passenger automobile and commercial automobile personal injury protection payments in excess of $75,000.
(b) For purposes of completing Schedule F of the annual statement, insurers shall consider the assumption and reimbursement by the Fund of private passenger automobile and commercial automobile personal injury protection payments in excess of $75,000 as a reinsurance transaction. Insurers shall consider assessments paid to the UCJF pursuant to N.J.S.A. 39:6-63 based on the insurer's premiums for private passenger automobile liability insurance (including PIP) and commercial automobile liability insurance (including PIP) as ceded premium, pro rated for the appropriate line of business on which the assessment was based.
(c) Insurers shall comply with the provisions of this section beginning with the annual statement due March 1, 1994 (covering the calendar year ended December 31, 1993). For purposes of completing the annual statement due March 1, 1993 (covering the calendar year ended December 31, 1992), insurers shall file by no later than July 1, 1993 a supplemental page 14 and schedule F of the annual statement in accordance with the provisions of this section.
11:3-28.10 Insurers' obligations to investigate and audit bills for medical benefits
(a) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by health care facilities where such claims are equal to or in excess of $25,000.
1. Failure of an insurer to complete an audit in accordance with these rules shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.
2. Per diem billings for health care facilities are not subject to the audit requirements set forth in this subchapter.
3. An insurer shall conduct an initial on-site audit for charges by health care facilities to determine whether the level of care, need and charges are appropriate.
4. An insurer may pay 80 percent of the provider's bill prior to completion of the initial on-site audit. The remaining amount due, if any, shall be paid following completion of the insurer's audit.
5. Annual on-site audits shall be completed in 12-month intervals, from the initial on-site audit and shall be filed with the Fund within 90 days of completion of the audit; and
6. Whenever a change in services occurs such as, but not limited to, the level of care, the daily room rate or additional charges, an insurer shall conduct an on-site audit and shall provide the audit and auditor's statement to the Fund with the next reimbursement request.
7. All other audits shall be conducted prior to payment to the health care facility and may be performed on a pre-screen basis as set forth in (e) below.
(b) For purposes of reimbursement by the Fund, an insurer shall conduct an investigation and audit of claims submitted by providers other than health care facilities where such claims are equal to or in excess of $10,000.
1. Failure of an insurer to complete an audit in accordance with this subchapter shall result in a 20 percent reduction in payment to the insurer by the Fund of the unaudited, reimbursable bill.
(c) The thresholds in (a) and (b) above are cumulative for each confinement associated with damages resulting from bodily injuries arising out of the ownership, maintenance or use of a motor vehicle in this State and shall incorporate all claims submitted per confinement by the provider.
(d) To be eligible for reimbursement by the Fund, insurers shall audit, prior to payment, bills submitted for continuous treatment from any provider which exceed or may exceed the applicable threshold.
(e) Audits of all providers conducted pursuant to this subchapter, including the audit of DRG bills and successor pricing, shall be performed by:
1. Licensed nursing personnel with two years experience or training in required auditing and hospital practices; or
2. An outside auditing firm retained by the insurer for such purposes.
(f) Audits performed shall include, but not be limited to, confirmation of compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29 including those situations where the insurer does not provide the primary coverage to the claimant.
(g) An insurer is not required to conduct a separate, independent audit, if it has obtained a true copy of an audit conducted by the primary insurer or health insurer.
(h) Insurers shall append copies of audits conducted, including those conducted by the primary insurer or health insurer, and the auditor's statements with the reimbursement request filed with the Fund in accordance with N.J.A.C. 11:3-28.7.
11:3-28.11 Modifications to vehicles
(a) An insurer shall obtain prior approval from the Fund for modifications to a claimant's vehicle, or vehicle to be used for the benefit of the claimant, the cost of which may be reimbursed by the Fund.
(b) An insurer shall submit a written request to the Fund, seeking approval of modifications which are equal to or in excess of $1,000, within 30 days of a claimant's request for modifications.
(c) A request to obtain prior approval from the Fund shall include the following:
1. A written recommendation for the modification by the claimant's primary care physician including:
i. Where the claimant is the operator of the vehicle, current findings on the claimant's physical ability to drive and a copy of the claimant's current driver's license;
ii. A brief analysis of the medical necessity and medical purpose for the requested modifications;
iii. A description of the purpose for which the vehicle will be used; and
iv. Verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident;
2. A cost benefit analysis, supported by appropriate documentation, comparing the cost of modifying the claimant's vehicle to the cost of alternate methods of transporting the claimant. This analysis shall incorporate an evaluation of the anticipated miles to be driven per year for medically necessary health care services, including a breakdown reflecting the number of miles to be driven to obtain health care service and the frequency of such services, the cost per mile of alternate means of such transportation, as well as the useful life of the vehicle;
3. An agreement between the insurer and the claimant setting forth, but not limited to:
i. The claimant's responsibility to maintain insurance on the vehicle; and
ii. The claimant's responsibility to repair and maintain the vehicle; and
4. Any additional information specifically requested by the Fund with regard to a particular application for approval.
(d) The insurer may independently evaluate, or be required by the Fund to evaluate, the claimant by a physician chosen by the insurer and approved by the Fund, at the insurer's cost, to determine whether a medical necessity and medical purpose exist for modifications to the vehicle. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above.
(e) The Fund shall not approve modifications to a vehicle unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident, are required for a medical purpose and the modifications are shown to be cost effective or as the Fund may otherwise determine.
(f) A request for modifications may be denied for failure to fulfill any of the above conditions.
11:3-28.12 Modifications to a claimant's residence
(a) An insurer shall obtain prior approval from the Fund for any modifications to a claimant's primary residence the cost of which may be reimbursed by the Fund.
(b) An insurer shall submit a written request to the Fund, seeking approval of modifications which are equal to or in excess of $10,000, within 30 days of a claimant's request for modifications.
(c) A request to obtain prior approval from the Fund shall include the following:
1. A written recommendation for the modification by the claimant's primary care physician including:
i. A brief analysis of the medical necessity for the requested modifications; and
ii. Verification that the requested modifications are necessitated by injuries sustained by the claimant in the subject accident;
2. Medical documentation estimating the claimant's life expectancy;
3. A cost benefit analysis, supported by appropriate documentation, which establishes that the proposed modifications are more cost effective than long term residential care services. The analysis shall include, in accordance with Appendix B incorporated herein by reference, an evaluation based on the life expectancy of the claimant and a comparison between the costs of the modifications and home care to be provided, to the costs of other residential care alternatives;
4. An evaluation prepared by an independent consultant experienced in barrier free designs that sets forth the type of modifications required and the costs of such modifications;
5. An agreement setting forth the responsibilities regarding the obligations of the claimant, the owner of the property or both and the insurer for, but not limited to:
i. The claimant's or property owner's responsibility for:
(1) The expenses for upkeep of the residence;
(2) Maintenance of insurance on the property; and
(3) Repayment to the insurer in the event of the claimant's relocation, death or upon the sale of the modified premises; and
ii. The insurer's obligation to remove nonessential equipment;
6. A repayment agreement with an amortization provision which provides an amortization term and amount, once a modification is determined to be cost effective, calculated in accordance with the formula provided in Appendix B to this subchapter; and
7. Any other additional information specifically requested by the Fund with regard to a particular application for approval.
(d) The insurer may independently evaluate, or be required by the Fund to evaluate, the claimant by a physician chosen by the insurer and approved by the Fund, at the insurer's cost, to determine whether a medical necessity for the modifications exist. The evaluation shall include a review of the elements considered in the primary evaluation as set forth at (c) above.
(e) The Fund shall not approve modifications to a residence unless it is demonstrated that the modifications are required for purposes of medical necessity resulting from injuries sustained by the claimant in the subject accident and the modifications are shown to be cost effective or as the Fund may otherwise determine.
(f) A request for modification may be denied for failure to fulfill any of the above requirements.
(g) Where a request for modifications is approved, the insurer shall record a lien against the modified property in the county in which the property is located and shall file a copy of the recorded lien with the Fund within 30 days.
1. This provision shall not apply to rental property.
(h) Where a claimant seeks to modify rental property, the insurer shall obtain:
1. A written consent from the owner of the property which permits the modifications and indemnifies the insurer and the Fund from any other liabilities relating thereto; and
2. A written agreement between the claimant and the insurer, in which the claimant agrees to reimburse the insurer for the unamortized costs of the improvements in the event of the claimant's relocation or death.
(i) Upon the claimant's relocation or death, the claimant, the claimant's estate or the owner of the property against which the lien is recorded, shall reimburse the insurer for the unamortized cost of the modifications to the claimant's residence.
(j) The claimant, the claimant's estate or the owner of the property against which the lien was recorded, shall have a reasonable period in which to reimburse the insurer.
(k) Where repayment by the claimant or the claimant's estate is required pursuant to this section, interest shall accrue at the prevailing rate of post judgment interest as set forth in the rules governing civil practice in the New Jersey Court Rules in effect at the time of execution of the repayment agreement, until the amount owed is paid in full.
(l) Within 30 days from the date of the claimant's relocation or death, the insurer shall so notify the Fund in writing and shall include the terms of repayment by the claimant to the insurer. The insurer shall repay the Fund for such reimbursement.
1. The insurer shall be required to repay the Fund within 60 days from receipt of any and all partial payments or from the receipt of a payment made in full by the claimant.
(m) A warrant discharging the lien shall be filed by the insurer when the full amount owed to the insurer, in accordance with the amortization agreement, is satisfied.
11:3-28.13 Insurer's obligation to obtain recovery of payments for paid medical expense benefit claims
(a) The Fund shall deny reimbursement to insurers for paid medical expense benefit claims if an insurer has failed to pursue any and all responsible tortfeasors within the time prescribed by law at N.J.S.A. 39:6A-13.1.
1. An insurer's failure to diligently pursue its right of recovery of medical expense benefit claim payments shall result in the denial of reimbursement by the Fund for these claims.
2. The Fund shall recover any reimbursement payments which were made to an insurer, where the insurer failed to diligently pursue its right of recovery against a tortfeasor.
3. An insurer shall obtain prior approval from the Fund before settling or compromising a claim against a tortfeasor.
(b) Any and all expenses and fees incurred by the insurer as a result of the pursuit of a right of recovery against a tortfeasor, shall be borne by the insurer.
11:3-28.14 Insurer's responsibility upon assignment of an uninsured motorist claim
(a) An insurer shall, within 10 business days of receipt of a claim assignment and accompanying instruction sheet (see Appendix B, Item 1, incorporated herein by reference) from the Fund, submit a letter to the Fund which:
1. Acknowledges receipt of the assignment and the accompanying instruction sheet; and
2. Provides the names and telephone numbers of the case handler or manager, the claim investigator and the claim adjuster.
(b) An insurer shall, within 10 business days from the date it assigns the claim to defense counsel, provide the Fund with the name, address and telephone number of defense counsel.
(c) An insurer shall, within 10 business days, provide written notice to the Fund of any changes, substitutions or replacements which occur with respect to any of the persons identified pursuant to (a)2 or (b) above.
11:3-28.15 Procedures for handling an assigned uninsured motorist claim
(a) Each insurer shall:
1. Perform an investigation in accordance with the procedures set forth in the instruction sheet and obtain the following:
i. Confirmation that there is no insurance available for the claim;
ii. Confirmation of the claimant's eligibility based on N.J.S.A. 39:6-70 or 39:6-78;
iii. A police report;
iv. Witness statements;
v. Copies of medical reports, bills and hospital records; and
vi. A central index bureau ("C.I.B.") report;
2. Forward to assigned defense counsel a copy of the instruction sheet for reference; and
3. Forward to the Fund's claim adjuster for certification responses to interrogatories propounded upon the Commissioner in hit and run cases.
(b) An insurer or assigned defense counsel shall obtain and file with the Fund, within five business days of receipt, all documents which relate to the claim including, but not limited to:
1. Documents relating to the discovery of information including, but not limited to:
i. Interrogatories propounded by the claimant and any responses thereto;
ii. Responses to interrogatories propounded by the insurer;
iii. Deposition notices; and
iv. Deposition transcripts;
2. Documents filed with the court including, but not limited to:
i. Motion papers;
ii. Briefs; and
iii. Settlement or consent agreements; and
iv. Orders entered by the Court; and
3. Scheduling notices, notices of arbitration and any results thereof; other correspondence from the courts; and any judgments or court decisions which affect the claim in whole or in part and copies of trial or hearing transcripts upon the request of the Fund.
(c) Within 60 days of receipt of a claim assignment, an insurer shall file with the Fund a completed 60-day Report as set forth in Appendix B, Item 2, incorporated herein by reference, and the following information:
1. The results of the investigation conducted in accordance with (a)1 above;
2. An estimate of the amount of damages involved;
3. A brief synopsis of the status of the case;
4. All answers to interrogatories not previously filed, which have been propounded on the Fund, the Commissioner or any known defendants;
5. Answers to interrogatories propounded by the insurer; and
6. Any other pertinent documents filed with the court in connection with the matter which were not previously forwarded to the Fund.
(d) At six-month intervals, following the initial receipt of a case assignment, an insurer shall file with the Fund an updated, detailed Six-Month Summary Report as set forth at Appendix B, Item 3, incorporated herein by reference, and the following information:
1. An update of the information set forth in (b) and (c) above;
2. A brief summary which describes the status of the case, outlines the action taken to date, sets forth anticipated future action and/or strategy; and the anticipated outcome;
3. The discovery of any evidence of a fraudulent claim. Such information shall be referred to an insurer's special investigation unit. The unit shall, thereafter, forward its findings to the Department's Fraud Unit with a copy to the Fund; and
4. All other relevant information discovered during the pendency of the claim.
(e) An insurer shall provide notice to the Fund of any and all hearings, motions, arbitration and trial dates in a manner which provides sufficient notice to facilitate the Fund's review of the file prior thereto. An insurer shall provide notice to the Fund's claim adjuster either by telephone and confirming letter, facsimile transmission or mail.
(f) An insurer shall consult with the Fund and obtain prior approval from the Board before:
1. Entering into a settlement or judgment by consent in accordance with N.J.S.A. 39:6-72 or 6-82;
2. Proceeding to trial; or
3. Filing a motion for reconsideration.
(g) An insurer shall consult with the Fund and obtain prior approval from the Board before filing an appeal from an order or judgment adverse to the Fund.
(h) Prior approval from the Board shall be obtained by telephoning the Fund at (609) 292-3100 or by writing to:
Unsatisfied Claim and Judgment Fund
Trenton, NJ 08625
(i) For each assigned claim, an insurer shall review all medical bills submitted by claimants to ensure compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29. Where a medical bill is not in compliance with N.J.A.C. 11:3-29, the insurer shall immediately notify the Fund of the discrepancy.
Failure of an assigned insurer to comply with these rules shall result in the imposition of penalties prescribed by law.
The Fund shall evaluate the cost effectiveness of modifications to a residence and shall establish an amortization schedule based on information submitted to the Fund by the insurer. The insurer shall file with the Fund the information in categories (a) through (d) below. This information shall be accompanied by the documentation which supports the information in those categories. The factors which shall be considered by the Fund include:
(a) Cost of modifications;
(b) Annual cost of home care, including but not limited to, nursing care, therapy, transportation for medical treatment and medical supplies;
(c) Life expectancy of the injured person;
(d) Annual cost of other residential care alternatives;
(e) Monthly amount amortized; and
(f) Term of amortization in months.
1. The formula which the Fund shall evaluate to determine the cost effectiveness of requested home modifications is as follows:
(a + (b x c)) < (d x c)
The Fund shall only approve modifications where the above formula applies.
2. The formula to determine the amount to be amortized monthly is as follows:
(d - b)/12 = e
3. The formula to determine the term of the amortization schedule is as follows:
a/e = f
The following examples demonstrate how the formulas shall be applied:
Example Example Example
One Two Three
Cost of Modifications 100,000 100,000 100,000
Annual Cost of Home Care 60,000 6,000 60,000
Life Expectancy of Injured Party 30 10 20
Annual Cost of Other Residential Care 84,000 120,000 60,000
Cost Effective Formula
Cost for Home Care 1,900,000 160,000 1,300,000
Cost for Alternative Care 2,520,000 1,200,000 1,200,000
Is Home Modification Cost Effective? Yes Yes No
Amount Amortized Monthly $2,000 $9,500
Term of Amortization 50 months 11 months