Five Important Things to Know About Med Pay in Virginia – Quick Tips For Insureds and Insurers.

Posted: April 06, 2015 by Abby V. Uzupis

            Medical Expense Benefits coverage – also known as “Med Pay” coverage – under Virginia law can be confusing for insureds and insurers alike.  Below are five simple, but important things, to know about medical expense benefit coverage in Virginia.  It should be noted that the information below deals with some general aspects of medical expense benefits coverage.  So, if you are an insured, you should always consult your insurance policy or speak with a claims representative regarding specific aspects of your coverage.  If you are an insurer, consult local counsel to make sure you are complying with Virginia law when administering medical expense benefits.
 
            (1)        What are Medical Expense Benefits?
 
            Medical Expense Benefits coverage is insurance coverage that will cover certain medical expenses should an insured suffer injuries as a result of a car accident, no matter who caused the accident. Under Virginia law, an insurer licensed in the Commonwealth of Virginia, issuing a policy for bodily injury or property damage liability insurance, must offer medical expense benefits coverage in the amount of $2,000 per person for “all reasonable and necessary expenses for medical, chiropractic, hospital, dental, surgical, ambulance, prosthetic and rehabilitation services, and funeral expenses, resulting from the accident and incurred within three years after the date of the accident.”  
 
            An insured can elect to decline medical expense benefits altogether or they can chose to increase their coverage over the statutory minimum of $2,000.
 
            (2)        Submitting a Claim to an Insurer
 
            If an insured gets into an accident and has to seek medical treatment for injuries caused by that accident, they may want to consider filing a claim with their insurance company under the Medical Expense Benefits portion of their auto insurance.  One of the major stumbling blocks to submitting a Med Pay claim is making sure all the proper documents have been submitted to the insurance company.  Certainly, an insured should first reach out to their claim representative and consult their policy to ensure they are providing all the proper documents.  However, generally, an insured must submit both their medical records and medical bills to their insurer to make sure they receive timely payment of medical expense benefits.  Oftentimes a claims representative cannot process a claim because they do not have all the proper paperwork.
 
            (3)        What is an Insurer Required to Pay?
 
            Under Virginia law, an insurer is only required to pay the medical expenses that were actually incurred as a result of a car accident.  In other words, an auto insurance company is only required pay: (1) the amount that an insured’s medical insurance company paid to cover the insured’s medical bills and (2) any co-pays made directly by the insured.  So, to circle back to Tip Number Two, an insured should provide their insurer with records that reflect any co-payments made and medical bills that reflect the amount paid by their medical insurance company.  Some medical bills will only include the amount charged by the medical provider and not the contractual write-off negotiated between the medical insurance company and the medical provider.   This information is important for quickly processing a Med Pay claim.
 
            (4)        Challenging the Reasonableness and Necessity of Medical Treatment
 
            Virginia law only requires auto insurers to pay medical expenses that are “reasonable and necessary,” and it is possible to challenge an insured’s medical expenses as neither reasonable nor necessary.  However, insurers must understand what is required under Virginia law to make such a challenge.  To begin, Virginia code states that, in an action for medical expense benefits payable under an auto policy, “the authenticity of bills for medical services provided and the reasonableness of the charges of the health care provider shall be rebuttably presumed.”  In other words, it is the insurers burden to put forth enough evidence to rebut the presumption that the medical bills were not reasonable.  To rebut this presumption, the insurer would have to present expert testimony that the medical expenses were unreasonable – i.e. beyond the customary amount charged for similar types of treatment.
 
             To rebut the necessity of medical treatment provided to an insured a result of a car accident, an insurer must rebut the insured’s testimony as to necessity with live testimony from an expert.  Virginia law does not permit an insurer to defend against a Med Pay claim via affidavit.
 
            (5)        Damages for Bad Faith Denials of Med Pay Claims
 
            Insurers must timely pay Med Pay claims and cannot make “bad faith” denials of those claims.  Virginia has enacted Va. Code § 8.01-66.1, which permits a court to award punitive, treble damages and attorney’s fees against an insurer if the court finds that an insurance company either: (1) untimely paid medical expense benefits, and/or (2) had no legitimate reason to deny an insured’s med pay claim.   Insurers should keep this statute in mind when considering the timeliness of payment and denials of benefits.



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