6.3 Part B Medical Payments

Part B - Medical Payments Coverage

Part B (Medical Payments) is a first-party, no-fault coverage. It pays reasonable and necessary medical and funeral expenses incurred because of bodily injury, caused by an accident, and sustained by an insured. Fault is irrelevant - if a covered person is hurt in a covered auto accident, Part B pays up to the per-person limit shown in the Declarations regardless of who caused the crash.

Limits are written per person, per accident (e.g., $5,000 each person). There is no per-accident aggregate that reduces an individual's limit - each injured insured gets the full per-person amount.

Two definitions of "insured" under Part B

Part B uses a two-track definition that the exam contrasts directly with Part C:

• Track 1 - You and family members: covered while occupying any auto (yours or someone else's) or as a pedestrian struck by a motor vehicle or trailer.
• Track 2 - Any other person: covered only while occupying your covered auto (a passenger in your car).

"Occupying" is defined as in, upon, getting in, on, out, or off the vehicle - so a person leaning on or stepping out of the car counts.

Trap: A guest passenger in your car is covered, but family members are also covered as pedestrians and in other people's cars; a non-family guest is NOT covered as a pedestrian or while occupying a different vehicle.

The 3-year time limit and coordination

Part B pays only for expenses incurred within 3 years of the accident date. Treatment beginning or expenses incurred after that window are not covered.

Because Part B is no-fault first-party coverage, it frequently stacks with other coverages: an injured insured may collect Part B medical and later recover BI damages from an at-fault driver's Part A. However, the PAP contains an 'other insurance' / non-duplication provision - Part B will not pay expenses already paid under the same policy's Part C or another auto policy's medical coverage. Insurers also retain subrogation/reimbursement rights when the insured recovers from a third party.

Part B exclusions

Medical Payments does not apply to bodily injury sustained:

• While occupying a vehicle with fewer than four wheels (a motorcycle).
• While using a vehicle as a public or livery conveyance (except share-the-ride carpools).
• While occupying a vehicle (other than your covered auto) furnished or available for regular use.
• During business use of a non-private-passenger vehicle, with limited exceptions.
• While the insured is employed in the auto business and injury arises out of that work.
• In the course of employment where workers compensation benefits are required or available.
• During war, nuclear hazard, or racing on a track.

Trap: Part B will not cover a motorcycle rider - candidates assume any vehicle accident triggers Med Pay.

What Part B actually pays for

Part B reimburses reasonable expenses for necessary medical, surgical, X-ray, dental, ambulance, hospital, professional nursing, and funeral services. Lost wages, pain and suffering, and general damages are not Part B benefits - those are recoverable only as liability (Part A) or UM/UIM (Part C) damages from an at-fault party.

Because Med Pay is modest (commonly $1,000 to $10,000 per person), it functions as fast, fault-free first-dollar coverage that pays before liability is sorted out. A claimant can use Part B for immediate bills and still pursue a third-party liability claim for the full measure of damages, subject to the insurer's reimbursement rights.

Worked coordination example

Assume the insured carries $5,000 Part B and is injured by an at-fault driver. Medical bills total $4,000. Part B pays the $4,000 immediately regardless of fault. The insured then settles a Part A liability claim against the other driver and recovers, among other damages, the same $4,000 of medical costs.

Under the non-duplication and reimbursement provisions, the insurer is entitled to be repaid the $4,000 it advanced under Part B out of that recovery, so the insured is not paid twice for identical expenses. If the bills had instead been $7,000, Part B would pay only its $5,000 limit and the remaining $2,000 would be pursued from the at-fault driver.

How Medical Payments Coverage Operates

Part B pays reasonable and necessary medical and funeral expenses caused by an auto accident and incurred within a set period (commonly three years) from the date of accident, regardless of fault. It is a first-party, no-fault style coverage: the insured collects from their own policy without proving the other driver was negligent, which makes it valuable for quick payment of the insured's and passengers' medical bills.

Who Is Covered and the Pedestrian Rule

Two insured groups exist under Part B. The named insured and family members are covered while occupying any auto or when struck as a pedestrian by a motor vehicle, broad protection that follows the person. Other persons are covered only while occupying the named insured's covered auto. A frequent exam scenario is the named insured injured as a pedestrian, who is covered, contrasted with a friend injured as a pedestrian, who is not, because the friend is covered only while occupying the covered auto.

Medical Payments Exclusions and Coordination

Part B excludes injuries while the vehicle is used to carry persons for a fee, while occupying a vehicle with fewer than four wheels (motorcycles), during business use of certain vehicles, and while occupying a vehicle furnished for the insured's regular use that is not the covered auto. Because medical payments overlaps with health insurance and with Part C and liability recoveries, policies coordinate to prevent duplicate payment; subrogation may apply where the insured recovers the same expenses from a liable party.