Medical Payments and Personal Injury Protection
Domain 3 - Medical Payments and Personal Injury Protection
This domain tests first-party injury coverage. You must distinguish Part B Medical Payments from state no-fault PIP, identify who is covered, and apply the time and exclusion rules.
Part B Medical Payments
Part B pays reasonable and necessary medical and funeral expenses incurred within three years of the date of an auto accident, up to the per-person limit. Fault is irrelevant. Covered persons include:
- you and family members while occupying any auto or while pedestrians;
- other persons occupying your covered auto;
- family members struck by an auto.
Typical exclusions are occupational injury covered by workers’ compensation, injury while occupying a vehicle with fewer than four wheels, racing, intentional injury, livery use, and unauthorized use.
PIP in no-fault states
PIP is not Part B. It is a state-mandated first-party benefit that may pay medical expenses, wage loss, essential services, and funeral costs regardless of fault. PIP often has a tort threshold that limits lawsuits for pain and suffering. Benefits and coordination with health insurance vary by state, so the PAP alone does not tell you the full PIP picture.
Worked example
A named insured’s daughter is a passenger in a friend’s car and is injured. Under her parent’s Part B, she is a family member occupying a non-owned auto, so Med Pay can respond to her medical bills up to the limit. The friend’s PAP may also provide Med Pay. In a no-fault state, PIP may be primary and Med Pay may be excess or unavailable, depending on the state’s rules. The reasoning: Part B follows the insured person, but state law can change the order of benefits.
Traps
- Med Pay does not pay lost wages; PIP may.
- Med Pay is no-fault, but it is not liability coverage and does not pay the other driver.
- The occupational exclusion is easy to miss for an injured worker.
- “Incurred within three years” is a coverage condition, not a suggestion.
- Do not quote a PIP limit from the PAP Declarations; PIP is separate.