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SIU Spotlight

Top 10 Recommendations for Addressing Fraud in NJ PIP Arbitration: A DRP’s Perspective

May 15, 2026

by Gary T. Lesser

New Jersey’s no fault PIP system presents a unique blend of statutory requirements, arbitration procedures, and evolving fraud schemes. For carriers, counsel, and SIU professionals, navigating this landscape effectively requires more than familiarity with the rules — it demands an understanding of how Dispute Resolution Professionals (DRPs) evaluate evidence, credibility, and patterns of abuse.

Drawing on more than a decade as a Forthright PIP arbitrator and extensive experience investigating staged losses and systemic fraud, I offer ten practical recommendations for strengthening fraud detection and improving outcomes in PIP arbitration.

1. Understand the NJ PIP Landscape

New Jersey’s PIP framework is unlike any other. Arbitration, not Superior Court, is the primary forum for resolving disputes, and Forthright’s DRPs adjudicate cases based strictly on the evidence presented. Appreciating the procedural nuances — including timelines, evidentiary expectations, and the limits of DRP authority — is essential for building a defensible case.

2. Spot the Red Flags Early

Fraud often reveals itself in the details. Early indicators include:

  • Overutilization of treatment
  • Templated or boilerplate medical reports
  • Conflicting timelines
  • Identical documentation across unrelated claimants

Identifying these patterns at the outset allows carriers to intervene before questionable treatment escalates.

3. Investigate Policy Level Fraud

Fraud doesn’t always begin with the accident. Policy level misrepresentations  — such as false garaging locations, unlisted household residents, or misrepresented vehicle use — can undermine coverage entirely. Scrutinizing these issues early can support dismissal applications under the PIP rules.

4. Use the PIP Arbitration Rules to Your Advantage

Rule 35 of the New Jersey No Fault PIP Arbitration Rules provides a mechanism for pre hearing dismissal when coverage requirements are not met. As the document notes:

“If any party contends that… there is no coverage or Forthright lacks subject matter jurisdiction, such party may apply for an Order dismissing the case prior to hearing.”

A well supported dismissal application — including policy provisions, factual support, and documentation — can resolve a dispute before it reaches a hearing.

5. Analyze Treatment Records for Patterns

Fraud rarely occurs in isolation. Comparing CPT codes, treatment patterns, and provider behavior across multiple cases can reveal systemic issues. Reviewing prior arbitration awards involving the same providers can also uncover recurring credibility concerns or previously identified irregularities.

6. Use SIU Strategically

SIU involvement is most effective when timed to coincide with treatment phases and targeted to specific concerns. Preparing SIU investigators with focused questions and clear objectives enhances credibility assessments and strengthens the evidentiary record.

7. Leverage the EUO Effectively

Examinations Under Oath remain one of the most powerful tools in the investigative arsenal. Choosing between recorded statements and EUOs depends on timing and strategic goals. Records should be used to challenge inconsistencies in patient testimony and to test the reliability of the claimant’s narrative.

8. Prepare Your Arbitration Submission Thoughtfully

A strong submission clearly identifies:

  • The legal issues
  • The evidence supporting your position
  • How the facts align with your defense theory

While written submissions are important, oral hearings often make the difference. DRPs value clarity, organization, and a well articulated argument.

9. Coach Your Witnesses

Witness credibility can make or break a case. Preparing witnesses for cross examination ensures they present confidently and consistently. DRPs evaluate demeanor, clarity, and the ability to explain complex issues without overreaching.

10. Understand DRP Limitations — and Read Between the Lines

DRPs decide cases based on the evidence presented, not investigative instincts. The civil burden of proof and limited credibility assessments shape outcomes. However, award language often contains subtle cues that can guide broader fraud detection efforts. Arbitration outcomes should be treated as investigative leads, not endpoints.

Conclusion

Fraud in New Jersey PIP claims continues to evolve, and carriers must adapt accordingly. By understanding the arbitration process, identifying red flags early, and presenting well supported cases, insurers can more effectively combat fraudulent activity while ensuring legitimate claimants receive the benefits they are entitled to.

These ten recommendations reflect a DRP’s perspective — one grounded in thousands of cases, systemic investigations, and a deep understanding of how fraud manifests in the PIP environment. With thoughtful preparation and strategic execution, carriers can significantly improve their ability to detect, challenge, and prevent fraudulent claims.

Firm Highlights

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Bret E. Dubbert Joins Marshall Dennehey’s Orlando Office as Special Counsel in the Casualty Department

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Bret E. Dubbert Joins Marshall Dennehey’s Orlando Office as Special Counsel in the Casualty Department

Thought Leadership

Commonwealth Court Reaffirms the Constitutionality of Act 111's IRE Provisions

In this case, the claimant sustained a work injury of January 6, 1994, which was acknowledged by Notice of Compensation Payable (NCP). After the claimant’s receipt of 104 weeks of temporary total disability benefits, the employer filed a Request for an Impairment Rating Examination (IRE). The IRE was performed in May 2023 and the IRE physician found that the claimant had a 5% whole person impairment, under the AMA Guides. The employer filed a Petition based on the IRE results, and the Petition was granted by the WCJ. During litigation, the claimant argued that the IRE provisions of Act 111 (Section 306(a.3) of the Act) were not applicable to her injury, since it predated June 24, 1996, the date Act 57 went into effect, and that the IRE provisions were unconstitutional. The Workers’ Compensation Judge (WCJ)) granted the Petition and the Board affirmed. On appeal to the Commonwealth Court, the claimant argued that Act 111 violated the nondelegation doctrine and that its retroactive application to the claimant’s injury was unconstitutional. The court rejected the arguments on the basis that they had already found the same arguments without merit in multiple, prior cases. The court also addressed an argument made by the claimant that Act 111 was procedurally defective under the Pennsylvania Constitution because it was only considered on two days in each House after having undergone amendments and reassignments. The court noted that the Pennsylvania Constitution requires every bill to be considered on three different days in each House. The claimant maintained that, according to the legislative history, the bill did not receive three separate days of consideration from each House when it was assigned a new bill number. The court pointed out, however, that the bill number, H.B. 1840 remained constant and was considered on three occasions by the House. Further, the court concluded that minor amendments to the bill were germane to its original subject, which was to modify the Act’s IRE process, in accordance with Protz II.

Marshall Dennehey Named a Standout in Litigation by BTI Consulting Group

News

Marshall Dennehey Named a Standout in Litigation by BTI Consulting Group

Event

CLM 2026 Focus Conference

Allison joins three insurance industry leaders to discuss how cyber coverage disputes, the growing impact of social inflation on bodily injury claim valuation, and the use of artificial intelligence are reshaping the bad faith landscape. The panel will examine emerging sources of extra-contractual exposure, including evolving cyber insurance coverage issues and the challenges of accurately valuing bodily injury claims. Practical approaches to claim evaluation using AI, along with defense strategies designed to help prevent or successfully defend against bad faith litigation, will also be addressed. 

Thought Leadership

Appellate Division Reversed Trial Judge's Orders Granting a Plaintiff's Section 40 Summary Judgement Motion

In Haskins v. Casey, et al., the plaintiff Dane Haskins worked for defendant Ekornes, Inc. (Ekornes) as a material handler. In June 2021, he filed a workers’ compensation claim petition for benefits due to a left shoulder injury in December 2020. He then resolved his workers’ compensation claim in November 2022 under an Order Approving Settlement. In January 2023, he filed a lawsuit against Ekornes and later amended to add additional claims and name other defendants, including the Ekornes president, chief financial officer, and director of human resources. In May 2025, a second amended complaint alleged that after he filed the workers compensation claim, Ekornes placed him on leave under the Family and Medical Leave Act (FMLA), denied his request for a work accommodation, and ultimately terminated him from employment in December 2021. He pleaded several causes of action asserting violations of the New Jersey Law Against Discrimination (LAD) as well as fraudulent concealment and wrongful discharge. The plaintiff then moved for partial summary judgment, seeking an order enforcing Section 40 of the Workers’ Compensation Act (WCA) as well as summary judgment on his FMLA claims. The defendants opposed the motions and cross-moved for summary judgment on the FMLA claims. After arguments, the court entered an order in December 2025, denying the FMLA motion and cross motion and granting the plaintiff’s Section 40 motion. In the order, the court permitted the plaintiff to pursue compensatory damages at trial in connection with the bodily injury claim. The court also allowed the plaintiff to present evidence of any workers’ compensation benefits to support his claim. The court then denied the defendant's subsequent reconsideration motion in February 2026. The defendants that appealed the Section 40 aspect of the orders. In reviewing the appeal de novo, the Appellate Division rejected the plaintiff's argument that the work-related injury arose out of his discrimination claims under the LAD. The plaintiff argued that he should be able to pursue a personal injury claim as a part of his LAD claim, noting that the employer’s compensation carrier would be able to assert a lien against any recovery against his LAD claims. In distinguishing between the Richter vs. Oakland Board of Education, 246 N.J. 507 (2021) case, in which the Court found that any recovery would be subject to a Section 40 lien as the allegation was that the defendants failed to accommodate her pre-existing diabetic condition, which resulted in bodily injury. In this case, the Appellate Division indicated that there was no bodily injury caused by Ekornes’ failure to accommodate a pre-existing disability. Rather, the shoulder injury was a result of a workers compensation claim, for which he received appropriate benefits previously. The Appellate Division noted that if the plaintiff was successful in proving his LAD claims, he would be entitled to damages caused by the discriminatory discriminatory conduct such as lost wages and emotional distress damages and that there will be no Section 40 lien. In addition, the Appellate Division disagreed that the petitioner could present evidence about and seek damages for his shoulder injury at trial. Although the petitioner argued that a defendant who retaliated against an employee for filing a workers’ compensation claim should not benefit from the exclusivity provision of the WCA, the Appellate Division noted that the Legislature did not include this type of scenario in the statue nor did any of the case law recognize this type of claim as a remedy. As such, the Appellate Division reversed the December 2025 order granting the the plaintiff’s Section 40 summary judgment motion as well as the February 2026 reconsideration motion order. The Appellate Division noted that they did not intend to limit the plaintiff in his pursuit of his other claims on under the LAD, FMLA, and workers’ compensation retaliation causes of action.

Result

Statutory Employer Immunity Upheld

In this construction accident case that resulted in a $5 million verdict, the Supreme Court of Pennsylvania upheld the Statutory Employer Doctrine, which immunizes general contractors and other contractors on construction sites when certain elements are satisfied.

Result

$19 Million Medical Malpractice Verdict Overturned

In this medical malpractice case, the trial court vacated $10 million of a $19 million verdict in post-trial motions and the Superior Court of Pennsylvania vacated the remaining $9 million on appeal.

Thought Leadership

WCJ Improperly Refused to Conduct C&R Hearing and Erroneously Required Settlement of All Pending Petitions

In this case, the claimant sustained injuries in the course and scope of her employment as a registered nurse. The employer acknowledged the injury by a Notice of Compensation Payable (NCP).  Subsequently, a Workers’ Compensation Judge (WCJ) expanded the description of injury. The employer then filed a Termination Petition, alleging the claimant was fully recovered from the injuries. Providers filed Utilization Review (UR) Petitions, challenging UR determinations finding their chiropractic treatment to be not reasonable and necessary. A settlement of the claim was eventually reached, and the employer filed a Petition to Seek Approval of a Compromise and Release (C&R) Agreement. The C&R outlined that the agreement fully resolved all future workers’ compensation claims except for the termination and UR Petitions. Briefs were filed and one day later, the WCJ issued an Interlocutory Order which stated if instructions were not followed regarding filing of a C&R, a settlement hearing date would not be given. The employer complied with the order, and filed the C&R. Subsequently, the WCJ notified the parties that the C&R must resolve all issues in the petitions, or would not be entertained. A settlement hearing was never held, and the WCJ then issued a decision, granting the Termination Petition and dismissing the UR Petitions. The WCJ also said that the Petition for Approval of a C&R was dismissed without prejudice, as the issues in the Termination and UR Petitions went to a decision. The claimant appealed to the Workers’ Compensation Appeal Board (Board). The Board granted the claimant’s appeal, finding that the WCJ violated the requirement of Section 449 that an expedited hearing be held when a Petition for Approval of a C&R is filed.  The Board further held that it was legally incorrect for the WCJ to insist that the C&R resolve all issues raised by the pending Petitions. The Board remanded the case to a new WCJ, and Employer appealed to the Commonwealth Court. The court affirmed the Board and held that the WCJ erred, as a matter of law, by refusing to hold an expedited hearing within 30 days, once the Petition for Approval of a C&R was filed.  The court noted that the language of Section 449(b) is mandatory, and a settlement hearing is not discretionary or dependent on a party’s separate request for a stay, or whether the record has been closed. The court further rejected Employer’s argument that the case should not be remanded to a new WCJ for a new decision on the termination and and UR Petitions, as the Board passed no judgment on whether the C&R Agreement resolved the termination and UR Petitions, and left it for the WCJ to decide in connection with the Petition for Approval of a C&R.

Result

$1.09 Billion Products Liability Verdict Overturned

In this products liability crashworthiness case, the Superior Court of Pennsylvania reversed a Philadelphia jury verdict of $1.09 billion, the largest verdict ever overturned by a PA appellate court.  The court ordered a new trial based on deficient jury instructions, clarified important aspects of crashworthiness law, and confirmed that so-called standard jury instructions may be incompatible with Pennsylvania law.