The "Serious Injury" Threshold in a No-Fault Car Accident Case

If you are injured in a car accident in a "no-fault" state, you may be able to step outside of the no-fault system and file a lawsuit for damages that you would otherwise be unable to claim. Here's how it works.

If you’re a driver or passenger injured in a car accident in one of a dozen or so states that follow a no-fault car insurance system, you’ll need to first turn to your own insurance coverage to get your medical bills paid, and to get reimbursement for lost income, in most cases.

(No-fault laws apply in the District of Columbia, Florida, Hawaii, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, New Jersey, New York, North Dakota, Pennsylvania, and Utah. See Car Accidents & Insurance Issues for legal information on no-fault and "PIP" claims.)

You can only step outside the no-fault system -- and file a liability claim or lawsuit against the at-fault driver -- if your accident resulted in "serious injuries." In this article, we’ll examine the type of injury that might meet the "serious injury" threshold - some states call it the "limited tort" threshold, or just the "lawsuit threshold" - allowing you to pursue compensation from the at-fault driver beyond that provided by a no-fault claim.

What is the Serious Injury Threshold?

If your car accident resulted in "serious injury," you’ll likely be able to step outside the confines of a no-fault system and file a liability claim or car accident lawsuit against the at-fault driver. Among other differences between no-fault and a standard claim, you’ll be able to get compensation for non-economic damages like pain and suffering if you pursue a claim outside of no-fault.

But, what is a "serious injury"? Each no fault state has a statute that outlines the types of injuries that would allow a plaintiff to file a lawsuit against the at-fault driver.

To illustrate, let’s take two examples; Florida and New York.

"Serious Injury" Under Florida’s No-Fault Laws

Florida’s no-fault rules require drivers to carry mandatory personal injury protection coverage (PIP), and this coverage will pay up to $10,000 for all injuries stemming from a car accident, with certain limitations -- including that the amount paid will only cover up to 80 percent of necessary medical treatment, and 60 percent of any lost income in most cases where the injured person is unable to work.

Your PIP coverage will kick in and pay for your losses, regardless of who was at fault for the accident. But the maximum amount recoverable per person is $10,000 under Florida's no-fault rules. If you've suffered losses that amount to more than $10,000 (or if your injuries qualify as "serious," as discussed below) you can step outside of the no-fault system and file a liability claim or personal injury lawsuit against the at-fault driver. But you can also purchase additional PIP coverage to increase this $10,000 maximum.

Remember that PIP protection also applies if you are a pedestrian or a bicyclist who has been injured in a car accident.

What is a "serious injury" for purposes of Florida’s no-fault law?

Here’s the relevant language, straight from the statute, Fla. Stat. Ann. section 627.737:

…a plaintiff may recover damages in tort for pain, suffering, mental anguish, and inconvenience because of bodily injury, sickness, or disease arising out of the ownership, maintenance, operation, or use of such motor vehicle only in the event that the injury or disease consists in whole or in part of:

(a) Significant and permanent loss of an important bodily function.
(b) Permanent injury within a reasonable degree of medical probability, other than scarring or disfigurement.
(c) Significant and permanent scarring or disfigurement.
(d) Death. 

What if your injuries do not qualify?

If you are limited to the no-fault option, here are the main drawbacks:

You can’t collect damages for non-economic losses such as pain and suffering.

As for property damage (the costs of repairing your vehicle after an accident, for example), that doesn't fall under the blanket of your PIP protection in Florida. If your car is damaged in an accident, you're free to file a third-party claim with the at-fault driver's insurance carrier, under that driver’s property damage liability coverage. Or, you can file a claim through your own collision coverage if you have it, if the accident was your fault.

Your injuries probably will not be covered if they occurred as a result of an intentional act, or while you were driving under the influence of drugs or alcohol; or while you were racing, driving a stolen car, or otherwise committing an act that amounted to a felony at the time you were injured.

"Serious Injury" Under New York’s No-Fault Laws

The maximum amount recoverable per person is $50,000 under New York's no-fault rules. If you've suffered losses that amount to more than $50,000 (or if your injuries qualify as "serious," as discussed below) you can step outside of the no-fault system and file a liability claim or personal injury lawsuit against the at-fault driver.

New York’s no-fault system covers:

  • All costs of medical treatment associated with the car accident, including psychiatric treatment and physical therapy (minus certain deductions that are specified in the statute).
  • Lost earnings up to $2,000 per month for up to 3 years (also minus certain deductions).
  • Other expenses that are tied to the accident and your injuries, up to $25 per day, for up to one year after the accident.

What is a "serious injury" for purposes of New York’s no-fault law?

Here’s the definition, straight from the statute, New York Insurance Laws section 5102(d):  

(d) "Serious injury" means a personal injury which results  in  death; dismemberment;  significant  disfigurement; a fracture; loss of a fetus; permanent loss of use of a  body  organ,  member,  function  or  system; permanent  consequential  limitation  of  use of a body organ or member; significant limitation of use  of  a  body  function  or  system;  or  a medically  determined  injury  or  impairment  of a non-permanent nature which prevents the injured person from performing substantially  all  of the  material  acts  which  constitute such person’s usual and customary daily activities for not less than ninety days during  the  one  hundred eighty  days immediately  following  the  occurrence  of  the injury or impairment.

What if your injuries do not qualify?

If you are limited to the no-fault option, here are the main drawbacks:

  • You can’t collect damages for non-economic losses such as pain and suffering.
  • As for property damage (the costs of repairing your vehicle after an accident, for example), that doesn't fall under the blanket of no-fault. If your car is damaged in an accident, your no-fault coverage won't apply, and you're free to file a third-party claim with the at-fault driver's insurance carrier, file a lawsuit, or go through your own collision coverage if you have it.
  • Your injuries probably will not be covered if they occurred as a result of an intentional act, or while you were driving under the influence of drugs or alcohol; or while you were racing, driving a stolen car, or otherwise committing an act that amounted to a felony at the time you were injured.
  • Overall, damages above $50,000 per person (i.e. medical payments, lost income, and anything else) are not recoverable.

It’s Not Always Clear

As you can see, some of the terms used in the definitions of "serious injury" are still a little vague. What is "significant" disfigurement or "significant" limitation of a body function? What is an "important" body function? What is a "permanent" injury? What kind of scarring is "significant"?

If you think your case qualifies as a "serious injury" under your state’s no-fault rules -- meaning you’re entitled to pursue a claim outside of the no-fault system -- you can expect an argument from the insurance company or the defense attorney representing the at-fault driver.  In order to argue that yours qualifies as a "serious injury", and that you should be able to sue for full damages, you’ll probably need to get an attorney of your own.

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