6.3 Part B Medical Payments

Part B — Medical Payments Coverage

Part B pays reasonable and necessary medical and funeral expenses incurred because of bodily injury caused by an auto accident, regardless of fault. It is first-party coverage: it pays for the insured's own injuries and those of passengers. Med-Pay is a low-limit, fast-paying coverage typically written at $1,000 to $10,000 per person and is designed to cover immediate out-of-pocket medical costs without waiting for a liability determination.

Who Is an Insured Under Part B

There are two distinct insured categories:

1. You and family members — covered while occupying any auto, and even as pedestrians if struck by a motor vehicle designed for use on public roads. This is portable coverage that follows the person.
2. Any other person — covered only while occupying your covered auto. A guest passenger in your car is covered; that same guest struck while walking is not covered by your policy.

'Occupying' means in, upon, getting in, on, out of, or off the vehicle.

Time Limit and Limit Application

Expenses must be incurred within 3 years from the date of the accident. The limit shown in the Declarations is the most paid per person, per accident, regardless of the number of insureds, claims, vehicles, or policies involved. With a $5,000 Med-Pay limit and four injured occupants, the insurer can pay up to $5,000 each — the per-person limit applies separately to each insured, not as an aggregate.

Worked Example — Per-Person Application

Med-Pay limit: $5,000 per person. The named insured's car (4 occupants) is rear-ended:

The $5,000 limit caps each person separately. There is no single per-accident ceiling on Med-Pay, so the insurer's total outlay can far exceed the per-person limit.

Part B Exclusions and Coordination

Key exclusions mirror Part A and add:

• Injury while occupying a vehicle with fewer than four wheels (motorcycles).
• Injury while the vehicle is used as a public or livery conveyance (ride-share trap repeats here).
• Injury occurring during the course of employment if workers' compensation benefits are required to be available.
• Injury while occupying a vehicle (other than your covered auto) furnished or available for your regular use.
• Injury sustained while the vehicle is used in the auto business or while racing on a track.

Coordination note: Med-Pay pays regardless of other coverage, but states with PIP (Personal Injury Protection) under no-fault laws may replace or supplement Med-Pay; in no-fault states PIP can be primary and broader (covering lost wages and essential services).

Med-Pay vs. Liability and PIP

Part B is first-party, no-fault within the auto context: it pays the insured's and passengers' medical and funeral expenses regardless of who caused the accident, but it is not the same as statutory PIP. The exam separates three first-party-adjacent ideas:

Subrogation and Coordination

Because Med-Pay pays without regard to fault, the insurer typically retains a subrogation/reimbursement right against the at-fault party once the insured is made whole, preventing a double recovery. When the insured also collects under Part A liability of another policy or under health insurance, the policies coordinate; Med-Pay does not pay the same expense twice, and the "other insurance" condition makes it excess in some fact patterns.

Reasonable, Necessary, and the Three-Year Window

Med-Pay covers only reasonable and necessary expenses for medically appropriate services, and only those incurred within three years of the accident date. An insurer may require proof of claim and an independent medical exam. A bill for a service rendered four years after the crash, or a treatment the insurer's IME finds unrelated, is properly denied - a common application item.

Interaction With the Per-Person Limit

The Declarations limit is the most paid per person, per accident, applied separately to each insured, with no aggregate per-accident cap. Candidates must be ready to total a multi-occupant example: with a $5,000 limit and four injured occupants whose bills are $7,200, $2,500, $6,000, and $900, Med-Pay pays $5,000 + $2,500 + $5,000 + $900 = $13,400, because each person draws on a full $5,000 limit and the insurer's total outlay can far exceed any single limit.

Med-Pay and the Household-Exclusion Trap

A recurring application point: Part B does not pay for injury sustained while occupying a vehicle furnished or available for the insured's regular use that is not the covered auto (for example, a company car driven daily but not on the PAP).

It also excludes injury during the course of employment when workers' compensation is available, injury while the vehicle is used as a public or livery conveyance, and injury occupying a vehicle with fewer than four wheels (motorcycles). Because Med-Pay pays quickly and without regard to fault, it functions as a goodwill bridge to a later liability or UM recovery, with the insurer typically retaining reimbursement rights to prevent the insured from collecting twice for the same expense.