6.3 Part B Medical Payments

Part B - Medical Payments Coverage

Part B pays reasonable and necessary medical and funeral expenses for an insured who is injured in a motor vehicle accident, regardless of fault. It is a first-party, no-fault-style coverage in the sense that the insured does not have to prove the other driver was negligent. Expenses must be incurred within a stated period after the accident, traditionally three years (36 months) from the date of the accident.

Because Part B pays without regard to liability, it provides fast, friction-free payment for the insured's own injuries and the injuries of passengers in the covered auto. It does not pay lost wages or pain and suffering; only medical and funeral costs.

Who is an insured under Part B

The Part B definition of insured differs from Part A. "Insured" means:

1. You or any family member while:
   • occupying a vehicle (any auto or trailer, owned or not), or
   • struck as a pedestrian by a motor vehicle or trailer designed for use on public roads.
2. Any other person while occupying your covered auto (so a passenger in the named insured's car is covered, but a passenger in a borrowed car is not unless they are a family member).

Occupying is defined broadly: in, upon, getting in, on, out, or off the vehicle. A person loading groceries while standing on the door sill is "occupying."

How the limit works (worked example)

Part B is a per-person limit that applies separately to each insured injured in the accident. Suppose the Declarations show Medical Payments $5,000 each person and a covered auto is in an accident carrying the named insured and two passengers.

The $5,000 limit is not a per-accident aggregate; each person has their own $5,000. Total paid here is $10,700. This per-person, non-aggregating structure is a favorite exam point: do not add the injured people together against one limit.

What Part B Pays and to Whom

Part B Medical Payments pays reasonable and necessary medical and funeral expenses, regardless of fault, for bodily injury caused by an auto accident, usually with a deadline (expenses incurred within 3 years of the accident). It is a small, fast, first-party coverage that smooths claims without litigating liability.

Covered persons are the named insured and resident family members while occupying any auto or as pedestrians struck by a motor vehicle, plus any other person while occupying "your covered auto." A passenger in the insured's car is covered; the insured walking across a parking lot and struck by a car is covered as a pedestrian.

Part B Exclusions and Coordination

Part B excludes injury sustained while the auto is used to carry persons or property for a fee (ride-share/livery without endorsement), while occupying a vehicle with fewer than four wheels, while the auto is used as a residence, during war/nuclear, or while occupying a vehicle the insured owns but did not insure under the policy.

Medical payments coordinate with other coverage but are not reduced by the insured's own fault. A common contrast question pits Part B (pays the insured's and passengers' medical bills no matter who caused the crash) against Part A (pays others' injuries only when the insured is legally liable). The same accident can trigger both: Part B pays the insured's family's medical bills while Part A pays the injured third party.

Reconciling the quiz math

Work it carefully: bills are $3,000, $5,500, and $7,000 against a $5,000 per person cap.

• Person 1: $3,000 -> pays $3,000 (under the cap)
• Person 2: $5,500 -> pays $5,000 (capped)
• Person 3: $7,000 -> pays $5,000 (capped)
• Total = $3,000 + $5,000 + $5,000 = $13,000

The lesson: cap each person individually, then sum. Never apply a single $5,000 limit to the whole accident.

Part B exclusions

Medical Payments does not apply to injury:

• While occupying a vehicle with fewer than four wheels (motorcycle).
• While the covered auto is used as a public or livery conveyance (rideshare-for-hire).
• While occupying a vehicle used in the auto business or any other business (except a private passenger auto, pickup, van, or trailer).
• Sustained while occupying a vehicle without a reasonable belief of entitlement to use it.
• Sustained in the course of employment if workers compensation benefits are required to be available (the WC exclusion).
• From war, nuclear, or radioactive contamination.

A frequently tested coordination rule: Part B can be excess or coordinated with health insurance and is typically a secondary payer where other coverage exists, but it pays regardless of who caused the crash.

Part B vs. liability and the subrogation point

Students confuse Part B with Part A. Part A (liability) pays the other party when the insured is at fault and requires proof of legal liability. Part B (medical payments) pays the insured's own group their medical bills with no fault inquiry and far smaller limits ($1,000 to $10,000 is typical). The same crash can trigger both: Part B pays the insured's passengers quickly, while Part A handles claims by the people in the other car.

Another tested concept is subrogation and reimbursement. If Part B pays an insured's medical bills and the insured then collects damages from the at-fault driver (or that driver's liability insurer) for the same expenses, the PAP's general provisions let the insurer recover its Part B payment so the insured is not paid twice for one bill. This prevents double recovery while still giving the insured immediate cash flow for treatment. Because limits are low, agents routinely recommend health insurance and UM/UIM as the primary protection and treat Part B as a fast first-dollar supplement.