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7.4 Part B – Medical Payments Coverage

Insuring Agreement​

Under Part B – Medical Payments Coverage, the insurer agrees to pay reasonable expenses for necessary medical and funeral services caused by an auto accident. To be covered, the injury must be sustained by an insured, and the expenses must be incurred within 3 years of the date of the accident. Unlike Part A – Liability Coverage, medical payments coverage does not depend on legal fault. This means payment may be available even if the insured was not legally responsible for causing the accident.

Part B Insureds​

Under Part B – Medical Payments Coverage, the Personal Auto Policy defines who qualifies as an insured for medical payments purposes. This definition is important because Part B pays medical and funeral expenses only when the injured person qualifies as an insured under this coverage. An insured under Part B includes:

  • The named insured or a family member while occupying any motor vehicle designed for use on public roads, or while occupying any type of trailer
  • The named insured or a family member as a pedestrian when struck by a motor vehicle designed for use on public roads, or by any type of trailer
  • Any other person while occupying your covered auto, such as a passenger riding in the insured vehicle

Insurance in Action

At the time of the accident, Sofia and Liam were both occupying the vehicle. Liam's mother and a family friend were also passengers. Although no one was seriously injured, each person needed medical care after the accident.

Under Part B – Medical Payments Coverage, Sofia, Liam, Liam's mother, and their friend may each qualify for medical payments coverage, subject to the Part B limit of liability. Because the limit applies separately to each insured, each injured person may be entitled to coverage for eligible medical expenses up to the applicable limit.

Liam also suffers a knee injury that may develop into a chronic condition. Medical expenses related to that injury may be covered if they are necessary, caused by the accident, and incurred within 3 years of the accident, subject to the Part B limit.

Part B Exclusions​

Although Part B – Medical Payments Coverage does not require the insured to be legally liable for the injury, several exclusions still apply. These exclusions limit coverage when the injury arises from certain vehicles, uses, employment situations, or high-risk activities.

Bodily injury to an insured is not covered when the injury is sustained:

  • While occupying a vehicle with fewer than 4 wheels, such as a motorcycle
  • While occupying your covered auto when it is being used as a public or livery conveyance
    • This exclusion does not apply to a share-the-expense car pool.
  • While occupying a vehicle being used as a residence, such as living in a car or occupying a permanently located motor home or trailer
  • During the course of employment, if Workers' Compensation benefits are available or are required to be available
  • While occupying, or when struck by, a vehicle other than your covered auto that is owned by the named insured or furnished for the named insured's regular use
    • A company car furnished for regular use is an example.
  • While occupying, or when struck by, a vehicle other than your covered auto that is owned by a family member or furnished for a family member's regular use
    • This exclusion does not apply to the named insured or the named insured's spouse.
  • While occupying a vehicle without a reasonable belief of entitlement to do so
    • Family members are considered to have a reasonable belief of entitlement when occupying your covered auto.
  • While occupying a vehicle being used in the business of an insured
    • This exclusion is intended to eliminate coverage for commercial vehicle exposures. However, it does not apply to a private passenger auto, pickup, van, or trailer.
  • While occupying a vehicle located inside a racing facility for the purpose of competing in, practicing for, or preparing for a race or speed contest

Part B also excludes certain bodily injuries caused by extraordinary or catastrophic events. Medical payments coverage does not apply to bodily injury caused by war, insurrection, rebellion, or the use of a nuclear weapon. Coverage is also excluded for bodily injury caused by, or resulting from, nuclear radiation or radioactive contamination.

Limit of Liability​

The limit of liability shown in the Declarations for Part B – Medical Payments Coverage is the most the insurer will pay for each person injured in any one accident.

Like the Part A liability limit, the Part B limit does not increase because multiple people, vehicles, or claims are involved. The stated limit is the maximum payable regardless of the number of:

  • Insureds
  • Claims made
  • Vehicles or premiums shown in the Declarations
  • Vehicles involved in the accident

If the same medical expense could be covered under more than one part of the policy, payment will not be duplicated.

Other Insurance​

If other auto medical payments insurance also applies to the loss, the insurer will pay only its pro rata share. This means the insurer contributes in proportion to its limit compared with the total limits of all applicable medical payments coverage. However, a different rule applies when the bodily injury occurs while the insured is occupying a non-owned vehicle. In that situation, Part B coverage applies as excess coverage over any other collectible auto insurance that provides payment for medical or funeral expenses.