How does PIP, MedPay and Health Insurance work?

Insurance Claims Denied LawyerIf you have Private Health Insurance but don’t have MedPay

PIP will automatically cover the first $2,000 in medical expenses and any medical expenses in excess of that amount will be submitted to your private health insurance to determine if medical coverage exists. If your insurance provider denies payment for a claim then you must submit that claim to the motor vehicle insurer that provided the PIP coverage.  Since Massachusetts statute mandates that claimants utilize existing health insurance for medical expenses exceeding the $ 2,000 limit on an automobile insurer’s PIP liability, the PIP carrier will deny a claim that was denied by the private insurance for failure to comply with the health insurance policy.

The most frequent denial of a claim by a private health insurance provider for failure to comply with the policy occurs when the claimant seeks medical treatment from a doctor outside the private insurer’s network. If the private insurer denies a claim because the claimant sought services that weren’t provided under the insurance coverage like chiropractic or dental treatments then the PIP carrier must pay for these costs.

If you have MedPay but don’t have Private Health Insurance

PIP will cover the first $8,000.00 in medical expenses and MedPay will take on any expenses in excess of $8,000.00 up to the MedPay policy limits.

If you don’t have Private Health Insurance or MedPay

The Massachusetts Auto Policy explains that PIP (Personal Injury Protection) will pay up to $8,000 in medical expenses and/or lost wages.

If you have Private Health Insurance and MedPay

PIP will cover the first $2,000 in medical expenses and anything above that amount will be submitted to your private health insurance carrier for their review. If the policy you have with your insurance provider contains deferral language then your insurance provider may, and likely will, deny the claim on the bases that you have MedPay and MedPay swill pay for the expenses in excess of $2,000.00.

There is statutory language in Mass. Gen. Laws ch. 90, 34A, Mass. Gen. Laws ch. 175, 111C or 113C, or any other statute prohibited such deferral. Therefore, the health insurer’s practice of denying coverage because of the existence of MedPay is permissible. (Metropolitan Pro. and Causality Co. v. Blue Cross) If your medicals then exceed your MedPay policy limits PIP will assume these expenses up to an additional $6,000.

If your policy doesn’t contain deferral language than your private health insurance company will be on the hook for any medicals exceeding $2,000. But as mentioned above, they will not be required to pay for expenses for services that weren’t permitted under the insurance policy. As is the case in number “2,” PIP may then deny the claim that was denied by the private health insurance provider (usually for treatment outside the private insurer’s network) at which time MedPay will kick in and assume the expenses.

Initial Consultations Are Always Free

A seasoned trial lawyer, Attorney Noonan represents plaintiffs in personal injury cases, wrongful death actions, and serious accidents.  He will aggressively seek to obtain a fair settlement for you for your injuries, but when insurance companies won’t settle, his law office has the experience and resources to take your case to trial.

Our knowledgeable and experienced Boston Personal Injury Attorneys at the Law Offices of Gerald J. Noonan are available to assist clients throughout all of Southeast Massachusetts, including but not limited to Brockton, Taunton, Bridgewater, Weymouth, Hingham, Quincy, Plymouth, Marshfield, Attleboro, Braintree, Rockland, Hanover, Duxbury,Whitman, Middleborough, Raynham, Mansfield, Avon, Canton, Stoughton and all smaller cities and rural areas in Southern Massachusetts. We also serve the counties of Plymouth, Norfolk, Bristol, Massachusetts.

No matter where you are located, we are just a phone call away. Call the Boston Car Accident Lawyer to schedule a free no-obligation case review and consultation at (508) 588-0422 and you will have taken your first step to find out how best to confront this important matter. You can also click here to use our Free Case Evaluation Form.

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