Med Pay Eligibility
Which of the following is NOT covered under Med Pay?
X-rays
Lost wages
Ambulance charges
Prescription medications
Lost Wages. Med Pay coverage includes typical medical expenses. Lost Wages would fall under the Liability (Bodily Injury) portion of the claim.
A store clerk breaks their wrist in the stockroom. Is Med Pay applicable?
No. Coverage C excludes injuries to employees. This would fall under Workers’ Compensation. The applicable exclusions are:
a. Any Insured
d. Workers’ Compensation and Similar Laws
A customer falls at the insured’s store but fails to report the incident. Fourteen months later, their attorney requests Med Pay coverage, stating treatment began a month ago. Is Med Pay applicable?
Under standard policy terms, Med Pay requires treatment and reporting within one year, so coverage wouldn’t apply.
If the Special Broadening Endorsement (421-2915 06/15) is included, the reporting window extends to three years. Still, the claimant must prove the injury meets the policy’s criteria (accident on premises or due to operations) for coverage to apply.
True or False: Medicare claims are exempt from the one-year reporting period.
True. Medicare recipients are exempt from the one-year benefit period requirement. Accordingly, MP coverage may still be triggered for a Medicare beneficiary even if the injury is reported after the one-year period has lapsed.
An independent contractor hired by the insured falls from a ladder while working on the insured’s premises. Is the contractor eligible for Med Pay?
No. Medical Payments coverage excludes injuries to hired persons (Exclusion b). It applies to the general public, not those with a contractual or employment relationship with the insured.
The contractor should seek coverage under their employer’s workers’ compensation. If the insured is found legally liable (e.g., due to negligence), the contractor may pursue a claim under Coverage A – Bodily Injury Liability.
A customer falls in a store on 6/1/2024 and reports the injury on 7/1/2025. They are not Medicare eligible. Is Med Pay coverage triggered?
No. It is past the one-year benefit period.
A tenant trips over a loose carpet in the hallway of their apartment complex. Is Med Pay applicable?
Yes. The tenant normally occupies the apartment, not the common area where the injury occurred.
A participant in a charity 5K, held at our insured’s premises, trips on uneven pavement and sprains their ankle. The insured reports the incident and inquires about our coverage of their medical costs. How do you respond?
MP coverage would be excluded in this case, as the claimant was participating in an organized sporting event, which qualifies as an athletic activity.
However, if our investigation determines that the insured was legally liable for the incident (e.g., due to negligent maintenance of the pavement), then the claimant’s medical expenses could be considered—but only under a liability claim, not under MP.
Additionally, we should confirm whether the insured has a formal contract in place with the sponsoring charity. The contract may contain favorable indemnification language allowing us to transfer risk.
The charity may also have a special event policy or participant accident insurance, which could cover the claim.
During a multi-day community festival hosted by our insured, a volunteer assisting with setup trips over a power cord and suffers a minor injury. The volunteer had signed a waiver provided by the insured before participating. The incident occurred on the insured’s premises, and the insured now wants to cover the volunteer’s medical expenses under Coverage C – Medical Payments. Does Med Pay coverage apply to a volunteer who signed a waiver?
A waiver may raise questions about liability and assumption of risk, but since Med Pay is a no-fault coverage, the waiver itself would not impact the applicability of Med Pay.
However, we would still need to verify the claimant’s status as a volunteer. This includes securing any relevant documentation—such as sign-in sheets, volunteer agreements, or contracts—and confirming that the individual was not compensated for their work.
If the claimant had any form of contractual or employment relationship with the insured, Exclusion b. – Hired Person could apply, which would preclude coverage under Med Pay.
A claimant is injured as they are getting off an exercise bike. Would Med Pay coverage be applicable?
No. Activities such as getting on or off exercise equipment (e.g., treadmill, stair stepper) are still considered part of the overall athletic activity. As such, they fall within the scope of the athletic activity exclusion, and MP coverage would not apply.
A tenant, Mr. Smith, lives in an apartment complex owned and managed by ABC Property Management. One day, while walking down the hallway of his apartment building — a common area — he trips over a loose carpet and injures his ankle. Mr. Smith submits a Medical Payments claim under ABC Property Management’s CGL policy, seeking reimbursement for his medical bills. Is Mr. Smith eligible for Med Pay? Why or why not?
Yes. Mr. Smith normally occupies his apartment complex, not the common area where he fell. Exclusion c. Injury On Normally Occupied Premises would not apply here.
The claimant slipped and fell on ice in the parking lot of a commercial building. The property owner had contracted our insured, under a signed seasonal agreement, to provide snow and ice removal services for the entire season. Is Med Pay applicable?
Yes, MP coverage is likely triggered because our insured has a signed agreement with the property owner to provide snow removal services for an entire season – the whole season is considered an [ongoing] operation. We would still need to verify that the loss occurred as a result of our insured’s operations for MP coverage to apply.