How Medical Payments Coverage Works in Virginia

 

Med Pay Insurance Pays Medical Costs and Covers Wage Loss if You Get Injured in a Motor Vehicle Crash

 

You can add Medical Payments Coverage (Med Pay or Medical Expense Insurance) when you buy bodily injury liability auto insurance in Virginia.

 

The purpose of this article is to explain how Med Pay insurance works in Virginia if you have been hurt in a motor vehicle accident and to help you get Med Pay if you need it. It addresses:

 

  • What Med Pay coverage is.

 

  • The amount of coverage available under Med Pay.

 

  • Whether you receive Med Pay coverage automatically when you purchase automobile liability insurance.

 

  • Whether you have to purchase Med Pay coverage.

 

  • How Medical Payments coverage works on a reimbursement system.

 

  • How to submit a claim to your Med Pay insurer.

 

  • What bills you should pay first using Med Pay.

 

  • Whether a health care provider can choose whether to receive payment through Medical Expense Insurance or your private health insurance coverage.

 

  • Whether you can use Med Pay insurance if you caused the car crash.

 

  • What to do if the insurance carrier denies your Med Pay claim without having a legitimate reason for doing so.

 

  • Whether Med Pay is a substitute for having private health insurance.

 

  • Whether you have to repay your auto insurance carrier for benefits received under Med Pay if you settle your car crash case.

 

  • How to stack Medical Expense Insurance coverage so that you get more benefits.

 

  • Common exclusions under Med Pay Insurance.

 

  • Whether you can file a negligence claim under tort law if you accept benefits through Medical Expense Insurance coverage.

 

  • What to do if you do not have Med Pay coverage.

 

If you have any questions about Med Pay coverage, or are looking for a top-rated Richmond car accident lawyer or Virginia Beach auto accident attorney, call me for a free consultation: 804-251-1620 or 757-810-5614. I’ll help you get fair value for your personal injury case.

 

What is Med Pay Coverage?

 

Med Pay coverage, also called Medical Expense Benefits (MEB), is a “no fault” insurance policy issued by your own automobile insurance carrier. It protects you if you are hurt in a motor vehicle accident.

 

In Virginia Med Pay coverage can be used to pay for medical bills and lost wages. It covers:

 

1. All reasonable and necessary expenses for medical, hospital, chiropractic, dental, surgical, rehabilitation, prosthetic, emergency medical, and funeral services resulting from a motor vehicle accident and incurred within three years of the date of the accident. This includes co-pays.

 

2. An amount equal to the loss of income incurred after the date of the accident up to $100 per week up to the date you are able to return to your usual occupation. Med Pay does not have to pay benefits for wage loss incurred more than one year after the date of the accident.

 

When is a Medical Expense Reasonable under Med Pay Coverage?

 

A medical bill is considered reasonable if it is “not excessive in amount, considering the prevailing cost of such services.”

 

Your Med Pay insurer may challenge the reasonableness of a bill, however, the authenticity of bills for medical services provided and the reasonableness of the charges is presumed. This means that the amount charged by your doctor is considered reasonable, no matter what it is, but the insurer can dispute the charge.

 

If the insurer believes the charges are unreasonable, it must hire an expert witness to testify why.

 

When is a Medical Treatment Considered Necessary under Med Pay Coverage?

 

Whether medical treatment is necessary under Med Pay insurance depends on:

 

  • Whether experts believe that the treatment can cure your injuries or relieve your suffering and symptoms.

 

  • Whether the treatment was rendered because of an injury suffered in the auto accident, not because of an unrelated condition or preexisting condition not aggravated by the car crash.

 

Whether medical treatment is necessary is determined by medical experts.

 

When is a Medical Expense Incurred for the Purpose of Med Pay Coverage?

 

In State Farm Mutual Automobile Insurance Co. v. Bowers the Virginia Supreme Court held that a medical expense is incurred when someone has paid it or is legally obligated to pay it.

 

You must consider the contracts between your health insurance plan and the health care providers when determining whether an expense is incurred and the actual amount of the expense incurred.

 

You must also incur the expense within three years of the date of accident. Even if you have received treatment within those three years, the expense is not incurred unless you have paid for it or have become legally obligated to pay for it within that period.

 

To get medical expenses paid under Med Pay coverage, I recommend signing a contract with your health care provider agreeing to pay for future medical treatment within the three year period. That way you can use Med Pay even if you receive the treatment outside of the three year period.

 

What Amount of Medical Expense Benefits Coverage is Available Under Med Pay Insurance in Virginia?

 

Your auto insurer must offer “up to $2,000 per person in medical expense coverage.” But it can offer more. I have seen medical expense limits near $50,000 per person, though this is not common.

 

Some Med Pay policies double the medical expense benefit limit if all occupants of the covered motor vehicle were wearing safety belts when the accident happened. This type of payment, which is called a personal auto special provision, is limited to a maximum increase of $10,000. Check your policy for this endorsement.

 

What Amount of Loss of Income Expenses are Available Under Med Pay?

 

Your auto insurance carrier can offer only $100 per week for loss of income under Med Pay. And this amount is available only if you are working for pay at the time of the accident.

 

Payments begin the first workday missed because of your auto accident. And will continue until you return to work, up to one year after the date of the accident.

 

This means you can receive up to $5,200 in lost income benefits under Med Pay.

 

Those of you who suffer catastrophic injuries resulting in permanent disability will likely exhaust your Med Pay lost income benefits.

 

Do I Receive Med Pay Coverage Automatically?

 

No.

 

Med Pay coverage is not provided automatically. You must purchase a Med Pay policy to receive coverage.

 

Do I Have to Purchase Med Pay Coverage in Virginia?

 

No.

 

You do not have to purchase Med Pay coverage in Virginia. The law requires only that you carry liability coverage for bodily injuries and property damage, as well as uninsured motorist coverage.

 

But your auto insurance company must offer Med Pay coverage and tell you that you have the option to purchase medical expense benefits coverage.

 

Who is Covered By Med Pay in Virginia?

 

There are three groups of people who can receive benefits under Medical Expense Insurance in Virginia:

 

  • Persons occupying the insured motor vehicle at the time of the accident.

 

  • The named insured on the policy if he or she is hurt while in, upon, entering, alighting from, or being struck by another motor vehicle while not occupying a motor vehicle

 

  • The spouse and relatives of the named insured on the Med Pay policy if that person is a resident of the named insured’s household and is hurt while in, upon, entering, alighting from, or being struck by a motor vehicle while not in a motor vehicle. Med Pay coverage may be available even if your body is not actually struck by another motor vehicle, but you are hurt by the impact of the two automobiles.

 

How Does Virginia Defined “Motor Vehicle” for the Purpose of Med Pay Coverage?

 

The Virginia Code defines “motor vehicle” as “every vehicle … that is self-propelled or designed for self-propulsion …”

 

It includes passenger cars, trucks, motorcycles, fork lifts, and even mopeds in some circumstances, depending on how fast the moped is going and where the moped is operated.

 

It does not include bicycles.

 

Who is Considered a Resident Relative Under Med Pay Coverage?

 

There is no statutory definition of “resident relative” in Virginia. Whether a person is a resident relative entitled to coverage under Medical Expenses Insurance is decided by common law.

 

A person is considered a resident relative under Med Pay if he or she is related to named insured by blood, marriage, or adoption. And if he or she is not merely a guest at the named insured’s home, but intends to reside there and does in fact stay there regularly.

 

It possible to be a resident relative at two different households. For example, a child injured in an auto accident may receive benefits under Med Pay if his parents are divorced and he spends time at both homes.

 

Always Read the Policy to Determine if Med Pay Coverage is Available

 

The insurance policy also defines who is covered under Medical Expense Insurance.

 

You and your attorney should obtain copies of all policies applicable to the motor vehicle you were occupying at the time of the accident, all policies in which you are a named insured, and all policies of any person who lives with you at the time of the accident. The policy may expand coverage. Or it may have exclusions that apply.

 

At a minimum the policy should incorporate the statutory language governing the provisions of medical expense insurance found in Section 38.2-2201(A) of the Virginia Code. This statute provides the minimum medical expense coverage an insurance company must provide. If there is a discrepancy between the statutory minimums and the language of the policy, the statute applies.

 

Medical Payments Coverage Uses a Reimbursement System.

 

If you have health insurance, Medicare or Medicaid, then you know that when you go to the doctor you present your insurance card and pay any co-pay that applies to that type of doctor.

 

The health care provider then bills your private health insurer. And you get a bill for any additional expenses owed under the terms of your private health insurance policy.

 

Med Pay does not work that way. Instead it uses a reimbursement system.

 

If you are injured in a motor vehicle accident and do not have private health insurance, then Med Pay is your primary coverage. You must first go to the hospital, doctor, or therapist and incur a medical expense. Then you or your attorney will submit a copy of the health care provider’s bill to the Med Pay insurer for reimbursement.

 

If you are injured in a motor vehicle accident and do have private health insurance, then you should use that insurance and make any co-pay require. Your Med Pay insurance is secondary to your private health insurance. So you should get a receipt for your co-pay and submit proof the co-pay to the Med Pay insurer for reimbursement.

 

How Do I Submit a Claim to the Med Pay Insurer?

 

Submitting a claim under the Medical Expense Benefits portion of your auto insurance or any other auto insurance that applies requires a lot of paperwork. Failure to comply with the paperwork is a major reason that claims for expenses under Med Pay are denied.

 

Generally you should submit not only a copy of the medical bill or co-pay receipt with your claim, but also a copy of the actual medical record. Once you submit both the bill and medical record, I recommend giving the insurance company up to three weeks to reimburse you.

 

What Bills Should I Use Med Pay Coverage For?

 

I recommend using Med Pay coverage for your hospital bills first. Hospitals can place a lien on your personal injury recovery. As a result, they are less likely to accommodate you while your personal injury claim is pending.

 

Your medical doctors or chiropractors may ask if you have Med Pay coverage. Then they will charge you full price since they think they will get paid through Med Pay. Make sure you get an estimate of charges before you treat with these providers. They should provide you a fair rate regardless of what coverage may be available.

 

Can My Health Care Provider Decide Whether to Bill Me Through Private Health Insurance or Medical Expense Insurance?

 

Only if you let them.

 

Previously insurance carriers would pay medical expense benefits to a health care provider directly. This changed, however, in 2013 when the General Assembly amended Virginia Code Section 38.2-2201(B) to state that payments under Med Pay coverage must be paid “to the covered injured person or pursuant to an assignment of benefits in accordance with subsection D” of the statute.

 

Subsection D of Section 38.2-2201 contains strict requirements for an assignment of benefits to be valid. And if the assignment of benefits is not valid, Med Pay benefits should be paid to you directly and not the health care provider.

 

I recommend that you not complete an assignment of benefits because: (1) you want to have control over your Med Pay funds so that you can hospital bills first and reduce the lien against your auto accident claim and (2) you want to use your health insurance coverage if you have it.

 

Section 8.01-27.5 of the Virginia Code addresses situations where you have both insurance and medical expense benefits. Often health care providers would have patients sign an assignment of benefits so that the provider could submit bills to the patient’s auto insurance company for payment under Med Pay instead of receiving payment from the health insurer. This would allow the health care provider to recover more money.

 

Now, however, a health care provider must submit its claim to the health insurer when you provide your health insurance information to the health care provider and the provider is in-network. Failure to do so prohibits the health care provider from recovering payment through your Med Pay coverage, even if there is a valid assignment of benefits.

 

Can I Use Med Pay for Medical Expenses if I Was at Fault for the Car Wreck?

 

Yes.

 

Med Pay provides “no fault” coverage for medical bills and expenses. This means you can collect medical expense benefits through Med Pay even if your negligence caused the motor vehicle accident.

 

Bad Faith: What are My Options if the Insurer Denies My Med Pay Claim?

 

If the insurance carrier fails to pay the Med Pay claim in a reasonable amount of time and its denial is in “bad faith,” then you may bring an action for damages.

 

Virginia Code Section 8.01-66.1 allows you to recover damages and attorney’s fees if the insurance carrier fails to pay medical expense benefits timely and has no legitimate reason to deny the Med Pay claim. This is known as an arbitrary refusal of payment.

 

Is Med Pay Coverage a Good Substitute for Private Health Insurance Coverage?

 

No. Med Pay is not a replacement for regular health insurance because:

 

  • Med Pay coverage is available for medical expenses related to injuries suffered in a car accident only. You cannot use the coverage unless you are hurt in a car crash.

 

  • There are limits on the amount of medical expenses Med Pay will cover.

 

Med Pay does, however, work well with private health insurance. Medical Payments coverage will help with most, or all, of the deductibles or co-pays you may owe under your regular health insurance. This reduces the amount of money you must pay out of pocket for medical care related to your car accident injuries.

 

Do I Have to Repay Benefits Extended under Med Pay Coverage?

 

Usually you do not have to repay money that the Med Pay insurance carrier paid to your health care providers. But some Med Pay carriers will claim they have a right to be reimbursed from the proceeds of your car accident settlement.

 

Make sure that you consult an injury attorney if the Med Pay insurance carrier asserts it is owed money. It should not take this position. You paid premiums so that you would have coverage in case you were hurt in a motor vehicle accident. When it does happen, the Med Pay carrier should not be entitled to reimbursement.

 

Section 38.2-2209, often called the Virginia Anti-Subrogation Statute, prohibits the inclusion of subrogation or repayment provisions for medical expense coverages in an automobile liability insurance policy.

 

Can I Stack Medical Expense Insurance With Other Auto Insurance Policies?

 

In insurance law the term “stacking” refers to combining multiple insurance coverages.

 

In Virginia you can stack Med Pay coverage in two ways: intra-policy stacking and inter-policy stacking. And the Virginia Code prohibits an insurance carrier providing medical expense insurance from taking a credit for coverage received through any other medical expense insurance. This means that an insurer cannot reduce its coverage of you if another policy paid for hospitalizations or medical treatment, including private health insurance.

 

Intra-Policy Stacking of Medical Expense Insurance

 

The Virginia Code allows a named insured or resident relative to stack up to four vehicles per policy when recovering Med Pay benefits.

 

For example, let’s say you purchased Medical Expense Insurance that provides up to $2,000 worth of coverage.

 

If you own three vehicles and each is insured under the policy, you may receive up to $6,000 worth of coverage.

 

If you own five vehicles and each is insured under the policy, you may receive up to $8,000 worth of coverage. You cannot multiply the base amount of coverage by more than four.

 

Inter-Policy Stacking of Med Pay Coverage

 

If you qualify as an insured under multiple policies, you may stack each of those policies.

 

For example, let’s say you are hurt while riding as a passenger in a relative’s car. You may stack coverage under the driver’s Med Pay policy with coverage under your own Med Pay.

 

It’s even possible to stack three policies if you are injured while riding in a motor vehicle operated by a person that does not own the motor vehicle.

 

In that situation benefits are paid according to the following order of priority:

 

  1. The medical expense insurance of the owner of the motor vehicle you were occupying at the time of injury.
  2. The medical expense insurance of the person driving the motor vehicle you were occupying at the time of injury.
  3. Your medical expense insurance.

 

Your attorney should review all available policies to maximize Med Pay coverage.

 

Common Exclusions Under Medical Expense Benefits Insurance Coverage

 

An insurance carrier offering Medical Expense coverage must offer coverage at least equal to that described in the Virginia Code.

 

The Supreme Court of Virginia, however, has stated that exclusionary language in medical expense insurance policies is valid and enforceable if it is clear, unambiguous, and not in conflict with the statute.

 

Typical exclusions in Med Pay policies include:

 

  • You cannot receive benefits if you intentionally cause injury to yourself.

 

 

  • You cannot receive benefits if you are injured while the automobile is not within the United States or Canada.

 

Generally you are excluded from receiving benefits under your Med Pay policy if you regularly use your employer’s vehicle or if you are hurt in a car accident while on the job.

 

Can I File a Personal Injury Lawsuit if I Collect Benefits through Med Pay Coverage?

 

Yes. You can still file a third-party personal injury claim against the driver who was responsible for your injuries, even if you collect Med Pay benefits.

 

What Should I Do if I Do Not Have Med Pay Coverage?

 

Auto accidents are the most common cause of catastrophic injuries in Virginia and the U.S. If you do not have Med Pay coverage then I recommend you call your insurance agent or insurance carrier and do the following:

 

1. Ask the insurance agent why he or she did not recommend you purchase Med Pay coverage. Med Pay coverage is inexpensive. It costs just a few dollars per year and provides benefits that are important if you are hurt in a car wreck. In fact, Med Pay coverage is a must if you do not have private health insurance to cover most of your medical bills.

 

2. Purchase Med Pay coverage and add it to your existing auto insurance policy. You should discuss the appropriate amount of Med Pay coverage with your insurance agent.

 

An Auto Accident Attorney to Help You Recover Medical Expense Insurance Benefits in Virginia

 

After a car accident I can help you use your Med Pay coverage to:

 

  • Make sure that doctors and other health care providers get paid quickly so that you are able to continue to receive medical care from these providers.

 

  • Make sure that you do not have to pay too much money out of pocket while you are waiting for your auto accident liability claim to settle.

 

  • Pay for co-pays, which can be thousands of dollars if you have serious car accident injuries that require extensive treatment.

 

  • Get every possible dollar out of all available policies to help you move forward with your life following an auto accident.

 

Call now for a free consultation: 804-251-1620 or 757-810-5614. If you’re in Virginia, I can help with your motor vehicle accident claim. This includes negotiating settlement of your medical expense insurance claim.

Corey Pollard
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