Getting Medical Payment Coverage to Work for You
How Do You Get Reimbursement for Medical Expenses with MedPay?
Medical Payments coverage reimburses the insured for the reasonable and necessary medical and funeral expenses related to an automobile accident. MedPay coverage amounts are typically sold amount ranging between $1,000 and $10,000. It is not uncommon to see MedPay policies for as much as $50,000 or even $100,000.
In determining what reasonable and necessary medical expenses the car insurance company may reimburse, it is important to understand what is meant by “reasonable” and “necessary.” A “reasonable” medical expense is one that is consistent with what is typically charged by a majority of similar medical providers within a given geographical area. A “necessary” medical expense is required and expected medical treatment rendered by an appropriately licensed medical provider who is practicing within their approved scope of medicine.
When you submit your medical bills and records for MedPay reimbursement, the adjuster will do one of the following:
- Reimburse the expense
- Deny the expense
- Partially reimburse the expense
- Ask for additional documentation
Following an accident, even if you have health insurance, MedPay coverage may help cover your co-pays or other related expenses. As such, it is important to explore each and every insurance policy that may provide you coverage.
How Long Does It Take to Get a Response?
Once you have submitted all of your medical bills and records to the MedPay adjuster, they will typically take an average of two to four weeks, depending on the insurance company or the adjuster, to review the request, process the request, and print the check if the expense is being reimbursed. If you are looking for a more specific timeline, it is a good idea to ask the adjuster for turnaround times for MedPay reimbursement funds.
It is important to be patient as there are usually several different departments involved with each step of the reimbursement process. The adjuster not only has to review the bills and records to make sure the treatment is relevant, but they must also ensure that the bills are reasonable. This review may require approval by a supervisor or by a group of supervisors called a “committee.” Some treatment may even need to be reviewed by a medical doctor that has been retained by the insurance company to ensure all treatment reimbursed was medically necessary and appropriate.
Once the treatment has been approved, the check has to be physically drafted by a separate department, which can take up to a week, and mailed to the appropriate location. Remember that this can and will take some time.
If it has been over a month, however, and you have not heard back from the adjuster about your reimbursement, it is a good idea to give the adjuster a polite follow-up call to check the status of the claim. If you have received a call from the adjuster about the documents you submitted, be sure to answer the call or return the call in a timely manner so that the adjuster can process your reimbursement as quickly as possible.
What Do I Do with the Check?
MedPay reimbursement is designed to cover medical expenses related to your accident. Assuming you do not have any medical liens, it is our recommendation that any MedPay checks you receive be used to pay off outstanding medical bills. The goal of an insurance claim is to get back what an accident cost you so that once you have reached a final settlement, you know that everything is taken care of and that you do not owe any money to any other medical provider. However, this will only be the case if you make sure to pay off your bills from your medical providers.
If you have already paid all of your medical providers, then what you receive is a true reimbursement check, meaning you can do with it as you see fit. Before you do anything with the money, you should contact each medical provider and confirm that you owe a $0 balance. It’s a good idea to get that confirmation in writing.
Important: If you have any medical liens, this process must be handled differently. Please review our guides on liens.
How Do I Know Which Treatment the Check Is For?
When the MedPay adjuster sends you the check, they should also include a document called an Explanation of Reimbursement (EOR), which contains an explanation of what was reimbursed related to your Medical Payments Claim.
This document will list information relevant to your claim, such as:
- The claim number
- Adjuster information
- Date of accident
It will also specify details about the reimbursement and should correlate with a Medical Payment check.
For example, if you submitted medical bills and records for a visit to the emergency room that cost $1,300 and have a MedPay limit of $1,000, you may receive a $1,000 check in the mail along with an EOR. This EOR should indicate the medical provider who provided the service related to the accident (the emergency room, in this case), the date of service received (or the date you went to the emergency room), the total amount charged (the $1,300), and the total amount reimbursed (the $1,000). In this case, you will probably see a note that $300 was not reimbursed due to the Medical Payment Reimbursement maximum being reached. This is to be expected and is nothing to be concerned about.
If you only have $1,000 in coverage, you cannot get reimbursed for that remaining $300 from your MedPay coverage. Depending on the company, you may get a letter in the mail a few days letter called an “Exhaustion Letter,” stating that your MedPay limit has been exhausted. This means the adjuster has paid all they would have to pay for your claim and will be closing your claim.
However, if you have a $2,000 MedPay limit in that same scenario, your EOR will likely show that $1,300 was charged and $1,300 was covered. This means that you still have $700 remaining in MedPay coverage. You should get EORs for each check you receive, and it is a good idea to verify that each check matches its EOR. If for some reason your EOR says you are going to be reimbursed $1,300 but you are only reimbursed $1,200, there may be a check printing error and you should call your adjuster immediately.
Depending on the company, your adjuster may send an Explanation of Reimbursement letter before your check, after your check, or with your check. If for some reason you get a check and do not get an EOR letter, call the insurance company and request that one be sent to you immediately.
Will Filing a Medical Payments Claim Raise My Premium?
Since MedPay is a no-fault insurance coverage, it is considered contractual in nature and, as such, should not cause your premium to increase. However, the specific nature of your contractual relationship is governed by the terms of your insurance policy with your insurance company or the insurance company providing coverage. It may be advisable to review the exact nature of the applicable insurance policy to determine the terms and nature of the contractual relationship.
When Will MedPay Not Apply?
There are numerous exclusions associated with North Carolina MedPay insurance policies that prohibit this type of coverage or exclude it from applying.
Here, we have listed some of the most common North Carolina MedPay exclusions that provide no coverage to any person for bodily injury received:
- While occupying a taxi or while transporting people or goods for money
- While occupying a motorhome or recreational vehicle
- While occupying any vehicle during the course of employment if workers’ compensation coverage is required or voluntarily given
- While occupying a vehicle without permission
- As a result or consequence of war, civil war, insurrection, rebellion, or revolution
- While using, operating, or occupying any motorized vehicle having less than four wheels
If you determine that there is more than one available MedPay policy providing coverage, you may be able to collect from each policy. However, your ability to collect from each available policy is limited by the fact that you are only permitted to collect up to the exact amount of your reasonable and necessary medical expenses incurred as a result of the motor vehicle accident. This means that you cannot submit that same bill to two different insurance companies, or “double dip” on MedPay coverage.
Hypothetical #1
You are injured in a car accident and incur reasonable and necessary medical treatment totaling $3,750. You assert a bodily injury claim for negligence against the at-fault driver and his insurance company (Allstate). You have MedPay coverage through your own insurance company (Geico), which is limited to $1,000 of coverage. Your adult daughter, who owns her own car and has her own insurance policy (Nationwide), lives with you. Her Nationwide MedPay coverage is limited to $2,500. How much MedPay can you collect?
Answer: You should be able to collect a total of $3,500 in MedPay coverage, given that your Geico policy of $1,000 is stacked upon your daughter’s Nationwide policy of $2,500.
Hypothetical #2
You are injured in a car accident and incur reasonable and necessary medical treatment totaling $1,750. You assert a bodily injury claim for negligence against the at-fault driver and his insurance company (Allstate). You have MedPay coverage through your own insurance company (Geico), which is limited to $1,000 of coverage. Your adult son, who owns his own car and has his own insurance policy (Nationwide), lives with you. His Nationwide MedPay coverage is limited to $2,500. How much MedPay can you collect?
Answer: As the golden rule of MedPay states, “You are only permitted to collect up to the exact amount of your reasonable and necessary medical expenses incurred as a result of the motor vehicle accident.” In this situation, you would only be able to collect $1,750 in MedPay, even though your Geico policy of $1,000 is stacked upon your son’s Nationwide policy of $2,500. Since MedPay coverage will not permit you to submit the same bill twice, your MedPay recovery is limited to $1,750 or the amount of related medical expenses incurred.
Time Limits for Seeking MedPay Coverage
The insurance company providing MedPay coverage is obligated to pay those reasonable and necessary medical expenses incurred as a result of a motor vehicle accident within three years of the date of the accident. For this reason, we strongly encourage you to act quickly if you need help seeking MedPay coverage.
Contact Wallace Pierce Law to discuss your situation and possible MedPay coverage with an experienced car accident attorney in Durham. We offer free initial consultations and there are no fees for you until we successfully win your case.
Call (919) 887-7892or contact us onlineto get started.
