NY A11596

Establishes that insurers may present fraud evidence even if claim denial is not issued within 30 days, including evidence that services were not provided, charges exceed permissible schedules by more than 10 percent, or the claim arose from intent to defraud.

Allows insurers to deny claims based on lack of medical necessity within 60 days after a claim becomes overdue, subject to review by a licensed provider with relevant expertise, with examination reports provided to claimant and treating providers within 30 business days.

Expands grounds for superintendent to prohibit health service providers from billing for no more than three years, including fraudulent insurance acts, unlicensed personnel use, billing for services not rendered, and unlawful ceding of business control; authorizes civil penalties up to $50,000.

Adds "complete tear or rupture" of nerve, tendon, ligament, cartilage or muscle to definition of "serious injury" to establish threshold for personal injury lawsuits beyond no-fault benefits.

Clarifies that "covered person" includes individuals injured in staged, planned or intentional accidents provided they are not perpetrators or knowing participants, and restricts insurer exclusion for intoxicated drivers to exclude necessary emergency hospital services.