Are Medical Benefits Covered Under My Automobile Insurance Policy?

Medical bills can be paid by different means. If you have Medical Payments ("Med Pay") or Personal Injury Protection ("PIP") coverage under your auto policy, your insurance company may pay your medical costs, whether you were at fault or not in the accident. These benefits are often included on automobile policies, but generally not on motorcycle policies. Some states, such as Washington and Oregon in our area, require that auto policies include PIP.

An injured person may be able to collect PIP or Med Pay benefits from the insurance policy that covers the automobile they were traveling in, or in the case of a pedestrian, the automobile they were struck by. In other cases, the injured person might receive PIP or Med Pay benefits from the insurance policy that covers their insured's automobile or an insured automobile of any member of their household.

It is important to find out soon after an accident exactly what types of benefits are available. There is no penalty for making a claim for PIP or Med Pay benefits. However, in most cases the insurance company who makes payments under PIP or Med Pay coverage will be entitled to reimbursement from the negligent party's insurance carrier.

What Medical Expenses Are Covered?

PIP and Med Pay benefits usually cover all reasonable and necessary medical bills incurred as a result of accident related injuries. These may include bills from doctors, hospitals, ambulances, physical therapists, chiropractors and prescriptions.

There is always a dollar limit or time limit on how much PIP or Med Pay insurance will cover. In addition, some policies have a deductible of up to $250. Send your medical bills to the PIP or Med Pay carrier, not the negligent party's insurance carrier. Until the claim is settled, that carrier is not under any obligation to pay anything, and generally they won't pay anything until the claim is settled in full.

What Wage Loss Is Covered?

Many PIP policies (but not Med Pay) will reimburse a portion of your lost wages. Typically, it is necessary for you to be off work for a period of time, often 14 days. Once this time has elapsed, you may be paid your wage loss until the maximum time period provided by the insurance policy. That maximum coverage period is frequently one year. Whether you receive payment for the initial waiting period depends upon state law. For example, in Oregon you would receive payment for the first 14 days, but in Washington you would not.

The policy will also designate how your wage loss is to be calculated, and there will be a maximum dollar amount. In some cases, only 70% of wage loss is paid up to the maximum. (Any wage loss not reimbursed to you from any PIP policy should be paid in the final settlement by the negligent party's insurance company.) If you have lost work as a result of an auto accident, be sure to find out what coverage may be available for you. You may even have some short term disability benefits available through your employer.

What Other Expenses Are Covered by PIP?

If you have PIP coverage and are not normally employed, you may be entitled to payment of expenses reasonably incurred for essential services that you would have performed had you not been injured. These may include babysitting, housekeeping, nursing care, etc. There is a limit to the amount per day and period of time, and again it is typically required that you first have been off work for a period of time, such as 14 days.

If the accident resulted in death, the family may find that some funeral benefits are included in PIP coverage.

What About My Losses Not Paid By PIP or Med Pay?

If there are no PIP or Med Pay benefits available, or your bills exceed the amount of your coverage, health insurance may be used to pay at least part of your medical bills. Other sources such as Medicare and Welfare, or a disability policy through your employer, may pay medical bills. In any event, all actual medical expenses and wage loss will be included at the time of settlement, even if you had no PIP or Med Pay coverage.

How Do I Apply for Benefits and What Documentation Is Needed?

There may be three types of documentation the adjuster needs to pay PIP or Med Pay benefits:

1. A completed Application for Benefits form. The insurance carrier should send you this form. Fully complete, sign and return it to the insurance carrier. The form contains an authorization for release of information, which allows the insurance carrier to obtain medical bills and reports from your doctors to verify that their bills are related to the automobile accident. By signing this authorization, you do not release your rights to an injury claim.
2. A doctor's note stating that you are unable to perform your job and the length of time you are released from work due to your injuries.
3. A wage loss form from your employer. The adjuster needs to know your rate of pay and the number of hours a week you work in order to compute your wage loss benefits. If you are self-employed, insurance adjusters will ask to see your business records and tax returns.

Check with your insurance company or agent to determine their exact requirements. If your medical bills and wage loss remain unpaid even though you have PIP or Med Pay coverage which should apply, arbitration can often be requested. A panel of arbitrators then decides your rightful claim.

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