Definitions used in this part only

Please note that each coverage section has its own definitions in addition to those that apply to the entire fault-based policy, set out for you in “Understanding Your
Auto Insurance Policy: Introduction”. Here are additional definitions for your vehicle insurance Med Pay provision:

An insured person, according only to this section’s definitions, means:
(1) You or any relative while occupying, or through being struck by, a highway vehicle or trailer;
(2) Any other person while occupying your insured car while the car is being used by you, a relative or another person if that person has permission. Your insured car also means a car not owned by you or a resident of your household or furnished for the regular use of either, when operated by you or a relative.

Your insured car also means a car not owned by you or a resident of your household, or furnished for the regular use of either, when operated by you or a relative. (This is in addition to the definitions for your insured car in “Understanding Your Fault Based Auto Insurance Policy: Policy Definitions”)

Agreement

This is what your insurance company agrees to pay for under Med Pay:

Coverage for medical expenses is usually from $1,000 to $10,000 per person, but it may be as high as $25,000 per person or more on some automobile insurance policies, depending on how much you want to pay for this coverage. Some of the terms subject to interpretation in the agreement are “reasonable expenses” and “necessary medical…treatment”. If you are injured and being treated by a chiropractor for back pain, for example, the insurance company may not believe it is “reasonable and necessary” for you to get treatment three times a week for 6 months. This is when the claims adjuster tells you to have a physical exam with the insurance company’s own doctor. Your refusal could jeopardize your right to receive benefits under this section of your fault-based policy (see “Understanding Your Fault-Based Auto Policy: Introduction”).

Exclusions (What Is Not Included)

As with liability coverage, there is a long list of situations
when your medical payments coverage does not apply. The more common exclusions that come into play but are not self-explanatory are further clarified below the list.

(1) In other words, you can’t be running a taxi or shuttle service where people are paying you for rides and expect the medical payments coverage of your policy to pay your passengers’ accident-related medical bills.

(2) If anyone is living in your car, there’s no med pay coverage available.

(5) If the injury occurs in a vehicle other than a private passenger vehicle used for the insured person’s work, there is no med pay coverage.

(6) If the injury occurs on the job, and if those injuries are also covered by workers’ compensation, there will be no med pay coverage.

Arbitration

If you (or your family or passengers) dispute the question of medical pay coverage under your auto insurance policy with your insurance company, you have the right to request a neutral arbitrator to settle the disagreement. The insurance company also has a right to request this. The two rather lengthy paragraphs and then the shorter third paragraph below are the policy language. Further explanations appear below them.

Explanations

If you cannot settle on an arbitrator, the court will appoint one. The court that appoints the arbitrator is also the court that will control any discovery (investigation) that needs to be done in order for each side to prove its claim. This means that all discovery must be conducted in accordance with the court rules.

The second paragraph refers to an insured person who not only has a medical payments claim on his own policy, but is also making filing for additional compensation under the uninsured motorist coverage of the policy, meaning the accident was caused, as least in part, by a driver with no insurance. The insurance company wants both the med pay and the uninsured motorist claims to be arbitrated together by the same arbitrator. The decision is binding and will be entered as a judgment in court.

Who pays for the arbitrator? That issue is covered, in our sample fault-based policy by reference to the California Code of Civil Procedure (your individual policy may differ from the statutory language given in the sample fault-based policy). It not so simply states that:

unless the arbitration agreement provides otherwise,… each party to the
arbitration shall pay his pro rata share of the expenses and fees of
the neutral arbitrator, together with other expenses of the
arbitration incurred or approved by the neutral arbitrator, not
including counsel fees or witness fees or other expenses incurred by
a party for his own benefit.

In other words, either you agree up front who pays, or you pay your proportional share plus your attorney and witness fees and any other expenses you incur to help your case.

Limits of Liability

Look in your policy for a section called “Limits of Liability.” This is the place that spells out the rules on how much your insurance company will pay for your med pay claim. In our sample fault-based auto insurance policy, the language is as follows (your individual policy may differ from the statutory language given in the sample policy):

Explanation

If your med pay coverage, which appears on the Declarations page that accompanies your policy, is $5,000, that is the total amount your insurer will pay for each injured person involved in the same accident, no matter how many vehicles were involved and whether or not the other vehicles were insured. If the same injured person is making both a med pay claim, and either a liability claim or an uninsured motorist claim on the same policy, any money paid for medical expenses under liability or uninsured motorist will be deducted from the med pay claim before the expenses are paid. In other words, no double dipping!

Double coverage: medical payments covered by more than one policy

What if you have more than one auto insurance policy? How do you collect with double coverage? In the section called “Other Insurance”, the policy tells you.

Explanation

If you have two policies that provide auto medical payments insurance, this auto policy will pay a proportionate share. Suppose this policy provides $2,000 in med pay coverage and your other policy provides $10,000 in med pay coverage. This policy will cover the amount of your medical bills times $2,000/$10,000, or 20% of the bills.

The second sentence refers to the scenario where you are a passenger in a vehicle insured under this policy, but it is not your vehicle. You have your own insurance policy with auto medical payments insurance. If you are injured in an accident in this vehicle, your med pay insurance from your own policy kicks in first, and the insurance policy of the car owner makes up the rest up to the policy limits for Med Pay.

Example: Suppose you are a passenger in your friend’s car, and your friend has a collision causing you injuries. Your medical bills are $6,500. Your friend has $5,000 Med Pay limits. You have your own auto policy for your vehicle with $2,000 Med Pay limits. Your own insurance policy would pay the first $2,000 towards your bills, and your friend’s policy would cover the remaining $4,500.

If, instead of $4,500, your remaining bills were $6,000, your friend’s policy would cover only $5,000 and you would be responsible for the balance of $1,000 (which your health insurance policy might pick up).

Payment Under Med Pay

The policy says:

This means that the insurance company may pay you, or whoever is responsible for paying your bills, or the medical provider directly, whichever they choose. You don’t appear to have a choice in the matter.