Making a No-Fault Claim Under Your Insurance Policy

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After your car accident, you can make no-fault injury claims under your Personal Injury Protection (PIP) coverage, your Medical Payments (MedPay) coverage, or maybe under both coverages.

PIP and MedPay claims are called "first-party claims." That means that they are claims that you make against your own insurance company. (Another example of a first party claim is one that you make under your homeowner's policy for weather damage to your house.) Just so you'll recognize the term if it ever comes up, claims that you make against an opposing insurance company are called "third-party claims."

PIP and MedPay are no-fault claims. That means that these insurance coverages pay benefits no matter who caused your accident. If you live in one of the no-fault car insurance states, these are usually the only injury claims that you can make. In fault insurance states, which are the majority, you can make no-fault claims against your policy and also make fault claims against the other driver's insurance company.

PIP Claims

PIP insurance covers medical expenses and, in some states, lost wages and other damages. It normally covers you, your passengers and any pedestrians that you strike. It may also cover you when you are riding in someone else's car, but in that case, the other driver's PIP coverage is probably "primary," meaning that it has to pay first. You can only make a claim under your coverage if you exhaust the other driver's coverage and you have a higher limit.

PIP is mandatory is some states, especially those with no-fault injury claim systems, and it is available in some other states, but not in all states. Because PIP coverages vary widely from state to state, be sure to review your policy and check with your insurance company about the specifics of your PIP coverage.

PIP claims normally have to be submitted within a specified time, so don't delay. In fact, don't delay at all. When you call your insurance company to report your accident, ask them to send you a PIP claim form. Then, fill out the claim form and send it in. You don't have to wait until you finish treatment and have all of your medical bills. You can send in your initial bills to be paid and then, when you incur more medical bills, you can send them in as a supplementary claim. And so on. Prompt payment will be appreciated by your doctor -- in whose hands your recovery rests. PIP coverages have maximum limits that can be paid, but they don't have deductible amounts that you have to pay.

MedPay Claims

Fault insurance states -- which are the majority of states -- normally have MedPay coverage, although some may have both MedPay and PIP coverages. MedPay covers you, your passengers and any pedestrians that you strike. It may also cover you when you are riding in someone else's car, but in that case, the other driver's MedPay coverage is probably "primary," meaning that it has to pay first. You can only go to your coverage if you exhaust the other coverage and you have a higher limit.

Again, when you call your insurance company to report your accident, ask them about your MedPay coverage and request the appropriate claim forms. Then, fill out the claim form and send it in. You don't have to wait until you finish treatment and have all of your medical bills. You can send in your initial bills to be paid and then, when you incur more medical bills, you can send them in. And so on. MedPay coverages have maximum limits that can be paid, but they don't have deductible amounts that you have to pay.

What Problems Should You Look Out For When You Make PIP/MedPay Claims?

Insurance companies are sometimes criticized for being much better at selling insurance policies and collecting premiums than they are at paying claims. Especially if your claim grows larger, you may be confronted with these excuses for not paying PIP or MedPay benefits:

  • Your doctor's charges are too high. They are not "ordinary and customary."
  • You are getting too much treatment. It is not "reasonable and necessary."

At some point, your insurance company may ask you to be examined by a doctor of their choice. They call this an Independent Medical Examination, but it definitely isn't "independent" at all. It is an attempt by your insurance company to get medical justification for limiting or ending benefit payments. If any of these problems crop up, consult a lawyer right away. Trouble is brewing.

What If You Have Both PIP And MedPay Coverages?

Normally, if you have both PIP and MedPay coverages, the PIP coverage is "primary," meaning that it pays first, and the MedPay coverage is "excess coverage" which kicks in after the PIP benefits are exhausted.

How Do These No-Fault Car Insurance Claims Integrate With Health Insurance?

In most instances, your no-fault car insurance coverage is first in line to pay your accident-caused medical bills. Then, if your no-fault insurance is exhausted, you turn to your health insurance for payment, if you have any. Then, if you make a claim against another driver and recover damages, you probably will have to repay your insurance company for the no-fault benefits that it paid and you almost definitely will be required to repay your health insurance company for payments that it made for your treatment.

You'll have to check the law of your state to learn whether you have to re-pay your car insurance company for PIP or MedPay benefits if you recover from another driver. You probably will not have to repay, but check before you resolve your claim since the answer to this question can dramatically affect your "bottom line." On the other hand, most health insurance contracts require you to repay your health insurance company for payments that it made as a result of your accident.

Conclusions and Recommendations

No-fault insurance laws vary from state to state, so the details of your no-fault coverage will depend on where you live. 

Keep in mind that there are no-fault claims that you can make against your own policy, even if you caused your accident. In some states, these are the only claims that you can make, while in other states, you can also make fault injury claims against another driver who caused your accident. Armed with this information, check your insurance policy and contact your insurance company to learn how your no-fault coverages work. Then use them. You paid for them.

Updated by: , J.D.

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