New Jersey § 39:6a-4

§ 39:6a-4.

Except as provided by section 45 of P.L.2003, c. 89 ( C.39:6A-3.3 ) and section 4 of P.L.1998, c. 21 ( C.39:6A-3.1 ), every standard automobile liability insurance policy issued or renewed on or after

the effective date of P.L.1998, c. 21 ( C.39:6A-1.1 et al.) shall contain personal injury protection benefits for the payment of benefits

without regard to negligence, liability or fault of any kind, to the named insured

and members of his family residing in his household who sustain bodily injury as a

result of an accident while occupying, entering into, alighting from or using an automobile,

or as a pedestrian, caused by an automobile or by an object propelled by or from an

automobile, and to other persons sustaining bodily injury while occupying, entering

into, alighting from or using the automobile of the named insured, with permission

of the named insured. “ Personal injury protection coverage ” means and includes: a. Payment of medical expense benefits in accordance with a benefit plan provided

in the policy and approved by the commissioner, for reasonable, necessary, and appropriate

treatment and provision of services to persons sustaining bodily injury, in an amount

not to exceed $250,000 per person per accident. In the event benefits paid by an insurer pursuant to this subsection are in excess

of $75,000 on account of bodily injury to any one person in any one accident, that

excess shall be paid by the insurer and shall be reimbursable to the insurer from

the Unsatisfied Claim and Judgment Fund pursuant to section 2 of P.L.1977, c. 310

( C.39:6-73.1 ). The policy form, which shall be subject to the approval of the commissioner, shall

set forth the benefits provided under the policy, including eligible medical treatments,

diagnostic tests and services as well as such other benefits as the policy may provide. The commissioner shall set forth by regulation a statement of the basic benefits

which shall be included in the policy. Medical treatments, diagnostic tests, and services provided by the policy shall

be rendered in accordance with commonly accepted protocols and professional standards

and practices which are commonly accepted as being beneficial for the treatment of

the covered injury. Protocols and professional standards and practices and lists of valid diagnostic

tests which are deemed to be commonly accepted pursuant to this section shall be those

recognized by national standard setting organizations, national or state professional

organizations of the same discipline as the treating provider, or those designated

or approved by the commissioner in consultation with the professional licensing boards

in the Division of Consumer Affairs in the Department of Law and Public Safety. The commissioner, in consultation with the Commissioner of the Department of Health

and Senior Services and the applicable licensing boards, may reject the use of protocols,

standards and practices or lists of diagnostic tests set by any organization deemed

not to have standing or general recognition by the provider community or the applicable

licensing boards. Protocols shall be deemed to establish guidelines as to standard appropriate treatment

and diagnostic tests for injuries sustained in automobile accidents, but the establishment

of standard treatment protocols or protocols for the administration of diagnostic

tests shall not be interpreted in such a manner as to preclude variance from the standard

when warranted by reason of medical necessity. The policy form may provide for the precertification of certain procedures, treatments,

diagnostic tests, or other services or for the purchase of durable medical goods,

as approved by the commissioner, provided that the requirement for precertification

shall not be unreasonable, and no precertification requirement shall apply within

ten days of the insured event. The policy may provide that certain benefits provided by the policy which are in

excess of the basic benefits required by the commissioner to be included in the policy

may be subject to reasonable copayments in addition to the copayments provided for

pursuant to subsection e. of this section, provided that the copayments shall not

be unreasonable and shall be established in such a manner as not to serve to encourage

underutilization of benefits subject to the copayments, nor encourage overutilization

of benefits. The policy form shall clearly set forth any limitations on benefits or exclusions,

which may include, but need not be limited to, benefits which are otherwise compensable

under workers' compensation, or benefits for treatments deemed to be experimental

or investigational, or benefits deducted pursuant to section 6 of P.L.1972, c. 70

( C.39:6A-6 ). The commissioner may enlist the services of a benefit consultant in establishing

the basic benefits level provided in this subsection, which shall be set forth by

regulation no later than 120 days following the enactment date of P.L.1998, c. 21 ( C.39:6A-1.1 et al.). The commissioner shall not advertise for bids for the consultant as provided in

sections 3 and 4 of P.L.1954, c. 48 ( C.52:34-8 and 52:34-9 ). Notwithstanding the provisions of P.L.2003, c. 18, physical therapy treatment shall not be reimbursable as medical expense benefits

pursuant to this subsection unless rendered by a licensed physical therapist pursuant

to a referral from a licensed physician, dentist, podiatrist or chiropractor within

the scope of their respective practices. Notwithstanding the provisions of P.L.2009, c. 56 ( C.45:2C-19 et al.), acupuncture treatment shall not be reimbursable as medical expense benefits

pursuant to this subsection unless rendered by a licensed acupuncturist pursuant to

a referral from a licensed physician within the scope of the physician's practice. b. Income continuation benefits. The payment of the loss of income of an income producer as a result of bodily injury

disability, subject to a maximum weekly payment of $100. Such sum shall be payable during the life of the injured person and shall be subject

to an amount or limit of $5,200, on account of injury to any one person in any one

accident, except that in no case shall income continuation benefits exceed the net

income normally earned during the period in which the benefits are payable. c. Essential services benefits. Payment of essential services benefits to an injured person shall be made in reimbursement

of necessary and reasonable expenses incurred for such substitute essential services

ordinarily performed by the injured person for himself, his family and members of

the family residing in the household, subject to an amount or limit of $12 per day. Such benefits shall be payable during the life of the injured person and shall be

subject to an amount or limit of $4,380, on account of injury to any one person in

any one accident. d. Death benefits. In the event of the death of an income producer as a result of injuries sustained

in an accident entitling such person to benefits under this section, the maximum amount

of benefits which could have been paid to the income producer, but for his death,

under subsection b. of this section shall be paid to the surviving spouse, or in the

event there is no surviving spouse, then to the surviving children, and in the event

there are no surviving spouse or surviving children, then to the estate of the income

producer. In the event of the death of one performing essential services as a result of injuries

sustained in an accident entitling such person to benefits under subsection c. of

this section, the maximum amount of benefits which could have been paid to such person,

under subsection c., shall be paid to the person incurring the expense of providing

such essential services. e. Funeral expenses benefits. All reasonable funeral, burial and cremation expenses, subject to a maximum benefit

of $1,000, on account of the death of any one person in any one accident shall be

payable to the decedent's estate. Benefits payable under this section shall: (1) Be subject to any option elected by the policyholder pursuant to section 13 of

P.L.1983, c. 362 ( C.39:6A-4.3 ); (2) Not be assignable, except to a provider of service benefits under this section

in accordance with policy terms approved by the commissioner, nor subject to levy,

execution, attachment or other process for satisfaction of debts. Medical expense benefit payments shall be subject to any deductible and any copayment

which may be established as provided in the policy. Upon the request of the commissioner or any party to a claim for benefits or payment

for services rendered, a provider shall present adequate proof that any deductible

or copayment related to that claim has not been waived or discharged by the provider. No insurer or health provider providing benefits to an insured shall have a right

of subrogation for the amount of benefits paid pursuant to any deductible or copayment

under this section.