What Is New York State's 'Serious Injury' Threshold

When you're injured in a car accident in New York, you might assume you can sue the at-fault driver for compensation right away. However, New York's no-fault insurance system creates a unique barrier called the "serious injury threshold." Our experienced New City car accident lawyers will explain this legal standard that determines whether you can step outside the no-fault system and pursue a personal injury lawsuit.

New York's No-Fault Insurance System Explained

New York operates under a no-fault insurance system, which means that after a car accident, you must first turn to your own insurance company for compensation, regardless of who caused the crash. This system was designed to reduce the number of minor car accident lawsuits flooding the courts and to ensure injured people receive prompt payment for their medical bills and lost wages.

Every driver in New York is required to carry Personal Injury Protection (PIP) coverage, also known as no-fault insurance, with a minimum of $50,000 per person. This coverage pays for your basic economic losses, including medical expenses, up to $2,000 per month in lost wages for 3 years, and up to $25 per day for other necessary expenses, such as transportation to medical appointments.

While this system provides quick access to funds, it comes with a significant limitation: PIP insurance only covers economic losses and does not compensate for non-economic damages, such as pain and suffering, emotional distress, or loss of enjoyment of life. To pursue these additional damages, you must meet New York's serious injury threshold.

What Qualifies as a Serious Injury in New York

Under New York Insurance Law Section 5102(d), a "serious injury" is defined as a personal injury that results in one or more of the following nine categories:

• Death: If the accident results in a fatality, the serious injury threshold is automatically met, allowing surviving family members to pursue a wrongful death claim.
• Dismemberment: The loss of a body part, such as an arm, leg, finger, or toe, qualifies as a serious injury under New York law.
• Significant disfigurement: Injuries that cause permanent, visible scarring or disfigurement, such as severe burns or facial injuries, meet this threshold.
• Fracture: Any broken bone qualifies as a serious injury. This includes fractures of varying severity, from hairline cracks to compound breaks.
• Loss of a fetus: Pregnancy loss resulting from an accident meets the serious injury threshold.
• Permanent loss of use of a body organ, member, function, or system: Complete and permanent loss of function in any body part or organ system qualifies.
• Permanent consequential limitation of use of a body organ or member: This category covers permanent, significant restrictions in how you can use a body part, even if you haven't lost function entirely.
• Significant limitation of use of a body function or system: Injuries that substantially limit how your body functions qualify under this category. New York courts have established that "significant" means "more than minor" - the injury must result in measurable, objective limitations supported by medical evidence.
• Medically determined injury or impairment of a non-permanent nature that prevents the injured person from performing all of their usual and customary daily activities for at least 90 days during the 180 days immediately following the accident: This is commonly known as the "90/180-day rule" and is one of the most frequently relied-upon categories.

The 90/180-Day Rule: A Closer Look

The 90/180-day rule provides an important pathway for injury victims whose conditions don't fall neatly into the other eight categories. This rule recognizes that even temporary injuries can be serious if they significantly disrupt your life for an extended period.

To qualify under the 90/180-day rule, you must prove that your injury prevented you from performing "substantially all" of your usual and customary daily activities for at least 90 days within the first 180 days after your accident. The 90 days do not need to be consecutive, but they must occur within that six-month window.

What Does "Substantially All" Mean

The phrase "substantially all" is critical to understanding this rule. New York courts have interpreted this to mean that your injury must have severely limited your ability to perform most of your everyday activities, not just some of them. If you could still complete many of your daily tasks with minor modifications, your injury likely wouldn't meet this standard.

Examples of activities that courts consider include:

• Going to work or performing job duties
• Personal hygiene and self-care
• Household chores and responsibilities
• Driving or using public transportation
• Recreational activities and hobbies
• Social interactions and family care

Proving the 90/180-Day Rule

Successfully proving that your injury meets the 90/180-day rule requires comprehensive medical documentation. Subjective claims about your pain or limitations are not sufficient - you need objective medical evidence.

This evidence should include:

• Detailed medical records from your treating physicians.
• Diagnostic test results such as MRIs, CT scans, and X-rays.
• Treatment notes documenting the extent of your injuries and limitations.
• Disability notes from your doctor explaining why you couldn't work or perform daily activities.
• Physical therapy records showing ongoing treatment.
• Expert medical testimony if your case goes to trial.

You should also maintain personal documentation, such as a daily journal tracking how your injuries affect your activities, pain levels, and limitations. Additionally, statements from your employer, family members, or caregivers who can corroborate your inability to function normally can strengthen your claim.

Common Injuries That May Meet the Threshold

While some injuries clearly meet the serious injury threshold - such as broken bones or amputations - many cases fall into a gray area. The following types of injuries often qualify, depending on their severity and impact on your daily life:

• Soft tissue injuries: Herniated discs, severe ligament tears, and significant muscle damage can meet the threshold if they cause measurable limitations supported by diagnostic imaging.
• Traumatic brain injuries: Concussions and more severe brain injuries often qualify if they result in cognitive impairments, memory problems, or functional limitations lasting 90 days or more.
• Spinal cord injuries: Injuries to the spine that cause permanent or significant temporary limitations in mobility or function typically meet the threshold.
• Whiplash: While often considered a minor injury, severe whiplash that prevents you from working or performing daily activities for an extended period can qualify under the 90/180-day rule.
• Internal organ damage: Injuries to internal organs that require surgery or cause lasting functional impairments meet the serious injury definition.

Challenges in Meeting the Serious Injury Threshold

Insurance companies routinely challenge claims based on the serious injury threshold. They employ various tactics to minimize payouts, including:

• Gaps in treatment: If there are unexplained gaps in your medical treatment, insurers may argue that your injuries weren't serious enough to require continuous care. Always follow your doctor's treatment plan and get documentation explaining any necessary breaks in treatment.
• Pre-existing conditions: Insurance companies may claim that your limitations existed before the accident. Medical records showing the difference between your pre-accident condition and post-accident injuries are essential.
• Surveillance: Insurers sometimes hire private investigators to surveil claimants and document their activities. If you're seen performing activities that contradict your claimed limitations, it can severely damage your case.
• Independent medical examinations: Insurance companies often request that you undergo an examination by their chosen doctor, who may downplay the severity of your injuries. Having your own thorough medical documentation is vital.

What Happens If You Meet the Serious Injury Threshold

If your injuries meet the serious injury threshold, you have several options beyond your PIP benefits:

• File a claim against the at-fault driver's liability insurance: New York requires all drivers to carry liability insurance with minimum limits of $25,000 per person and $50,000 per accident for bodily injury. You can pursue compensation from this policy for your damages exceeding your PIP coverage.
• File a personal injury lawsuit: If insurance negotiations don't produce fair compensation, you can file a lawsuit to seek full damages, including pain and suffering, emotional distress, loss of enjoyment of life, and future medical expenses.
• Pursue additional PIP benefits: If you purchased Optional Basic Economic Loss (OBEL) coverage, which provides an additional $25,000, or Additional Personal Injury Protection (APIP), which extends coverage beyond the basic $50,000, you can access these benefits.

When you meet the threshold, you can recover compensation for both economic and non-economic damages, including medical bills exceeding your PIP coverage, lost wages and loss of earning capacity, pain and suffering, emotional distress, loss of enjoyment of life, and permanent disability or disfigurement.

The Motorcycle Exception

An important exception to the serious injury threshold applies to motorcycle accidents. Motorcyclists in New York are not eligible for no-fault insurance benefits because motorcycles are not covered under the state's PIP requirements. As a result, the serious injury threshold does not apply to motorcycle accident victims.

If you were injured in a motorcycle accident, you can file a lawsuit against the at-fault driver for any injuries you sustained, regardless of whether they meet the serious injury definition. This means you have immediate access to compensation for pain and suffering, even if your injuries would not have qualified under the threshold in a car accident.

Time Limits for Filing Your Claim

New York law imposes strict deadlines for personal injury claims. You generally have three years from the date of the accident to file a personal injury lawsuit. However, certain administrative requirements must be met much sooner:

• You must notify your insurance company of the accident within 30 days.
• Medical bills must be submitted to your PIP insurer within 45 days of treatment.
• Lost wage claims must be filed within 90 days.

Missing these deadlines can result in a denial of your claim, so prompt action is essential.

Get Help from Fellows Hymowitz Rice

At Fellows Hymowitz Rice, our attorneys have decades of combined experience helping injury victims throughout New York City and the surrounding counties prove their serious injuries and recover maximum compensation. Contact us today for a free consultation to discuss your case and learn how we can help you get the justice and compensation you deserve.