What Happens When Your $5,000 in Car Insurance Medical Benefits Runs Out?
Every Pennsylvania auto policy has to include at least $5,000 in medical benefits, often called first-party benefits or PIP. After a serious crash, that money can be gone in a single ambulance ride and ER visit. Many people only find out how much coverage they chose when the insurance company sends a letter saying it has run out.
Running out of auto medical benefits doesn't mean your care stops being covered. It means the bills move to the next source in line. Here's how that usually works.
Step 1: Your auto medical benefits pay first
In Pennsylvania, your own auto policy generally pays your medical bills first, no matter who caused the crash. The legal minimum is $5,000, but many people carry more, such as $10,000, $25,000, $50,000 or $100,000. Check the declarations page of your policy. If you don't own a car, a policy belonging to a relative you live with may apply. See Who Pays Your Medical Bills After a Car Accident?
While auto benefits are paying, doctors and hospitals are generally limited by law to a set fee schedule. They're not supposed to bill you for the difference.
Step 2: Health insurance usually picks up next
Once your auto medical benefits are used up, your health insurance generally becomes responsible. That includes private plans, employer plans, Medicare and Medical Assistance (Medicaid). Your normal co-pays, deductibles and network rules usually apply.
Give every provider both your auto claim number and your health insurance information, and tell them when your auto benefits are exhausted.
Ask your auto insurer for a letter confirming the benefits are used up. Health insurers often ask for it before they pay.
Keep copies of every bill and explanation of benefits you receive.
Step 3: The claim against the driver who caused it
Medical bills beyond what your auto benefits covered can be part of your claim against the at-fault driver, along with lost wages and, depending on your tort option, pain and suffering. Pennsylvania doesn't let you recover the same bills twice, so amounts your own auto benefits paid generally aren't part of that claim.
If your health insurance paid bills after your auto benefits ran out, it may have a right to be repaid out of your settlement. That repayment, called a lien or subrogation, can sometimes be reduced. See Who Gets Paid Back Out of Your Settlement.
If the other driver has little or no insurance, your own uninsured or underinsured motorist coverage may help. See Uninsured and Underinsured Drivers.
What if you don't have health insurance?
This is where people get into trouble. Some providers will keep treating you and wait to be paid from your settlement, sometimes under a written agreement. Others will send bills to collections. You may also be eligible for Medical Assistance, sometimes retroactively. Talk to the hospital's financial counselor early, and don't stop treatment you need because of a bill. Gaps in care can hurt both your recovery and your claim.
Lost wages and other first-party benefits
Medical benefits are the only first-party coverage Pennsylvania requires. Some policies also include income loss, funeral or other benefits if you chose them. If yours doesn't, lost wages generally become part of the claim against the at-fault driver. See Lost Wages After an Accident.
Before the next crash: check your coverage
Raising medical benefits above $5,000 often costs less than people expect. It's worth asking your agent about medical benefits, income loss, uninsured and underinsured motorist coverage and your tort option at your next renewal. See Limited Tort vs. Full Tort.
Talk it through with someone local. If the medical bills from your accident are piling up faster than your coverage, the attorneys at Joyce, Carmody & Moran can help you sort out who should be paying. Request a free consultation.
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