The Okonkwo Family and Two Separate Injuries
The Okonkwos' PAP shows $5,000 of medical payments coverage; they live in a tort-liability state, not a no-fault state. Their son Emeka, 22, is a full-time student living at home. Riding in the back seat of a friend's Civic, he was rear-ended at a stoplight; his bills reached $31,000 and he lost $4,800 in wages over six weeks. The Civic's owner carries $10,000 of medical payments coverage. Emeka also has student health insurance with a $3,500 deductible and a coordination-of-benefits clause. The friend's liability insurer has already accepted fault. Four months before the crash, Emeka was struck by a car while riding his bicycle in a crosswalk; that driver's insurer also accepted liability. Last week Emeka's chiropractor submitted a $1,900 bill for treatment related to the bicycle accident, dated 41 months after that accident.
1. Is Emeka an insured for medical payments in both accidents, even though he was not in a covered auto in the second one?
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Yes to both. Medical payments coverage under the PAP insures the named insured and family members for reasonable expenses incurred because of bodily injury caused by an accident while occupying a covered auto, while occupying a non-owned auto, or as a pedestrian when struck by a motor vehicle. Emeka is a resident family member, so he is an insured in his own right rather than merely an occupant of someone else's car. Being struck while riding a bicycle in a crosswalk places him in the pedestrian category, which is the classic trap question: the bicycle is not an auto, but the injury was caused by one. Fault is irrelevant to Part B, so the fact that the motorist's insurer accepted liability does not make the coverage unavailable; it only creates a subrogation opportunity for the MedPay payer against the at-fault driver.
2. The Civic's policy has $10,000 of MedPay and the Okonkwos' has $5,000, and there is health insurance. In what order do these pay, and are the lost wages part of MedPay?
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Start with the form. Part B's other-insurance condition makes the two auto MedPay policies share pro rata rather than stack in a strict primary-excess ladder: the Okonkwos' share is its $5,000 limit divided by the $15,000 of applicable auto medical limits, one third, and the Civic's carrier bears two thirds, each up to its own limit. Fault plays no role in either computation. Health insurance then turns on the coordination-of-benefits clause, and most group plans make auto medical payments primary for injuries arising out of an auto accident, so the health plan generally pays after the auto MedPay is exhausted and after the $3,500 deductible. Lost wages are not a medical payment item under the PAP at all; that economic loss belongs to a liability claim against the at-fault driver, or to PIP where a no-fault state applies.
3. Can the Okonkwos submit the $1,900 chiropractic bill from the bicycle accident to MedPay?
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No, not under Part B. Medical payments coverage is limited to reasonable expenses incurred within three years from the date of the accident. The treatment is dated 41 months after the bicycle accident, so it falls outside the coverage window and the carrier should deny it on that ground alone, regardless of whether the treatment is reasonable and necessary. Two follow-on points matter. First, the three-year cutoff is measured from the date of the accident, not the date of first treatment, so a late-presenting injury does not reset the clock. Second, denying Part B does not extinguish the claim: the injured person may still pursue the at-fault driver under liability, subject to the statute of limitations for bodily injury in that state, and the health plan may cover the treatment as an ordinary medical expense.