MedPay Coverage in Georgia: Using Your Own Insurance First

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Medical payments coverage, known as MedPay, is the part of a Georgia auto policy that pays medical bills after a crash without regard to who caused it. Georgia’s Code defines it as coverage in which the insurer agrees to reimburse the insured and others for reasonable and necessary medical and funeral expenses “without regard to the insured’s liability for the accident.” Whether a policy includes it is a choice, because insurers must file MedPay forms and rates but are not required to offer it. Using it first affects the later injury claim in specific ways that another statute controls: when the MedPay insurer can be repaid from the recovery, and what it cannot do to collect.

What MedPay Covers

OCGA 33-34-2(1) defines “[m]edical payments coverage” as “any coverage in which the insurer agrees to reimburse the insured and others for reasonable and necessary medical expenses and funeral expenses incurred as a result of bodily injury or death caused by a motor vehicle accident, without regard to the insured’s liability for the accident.” Three features follow from that text:

  • Fault does not decide payment. The coverage applies “without regard to the insured’s liability for the accident,” so a driver who caused the crash can use it as well as one who did not.
  • It reaches passengers. Coverage “shall be available to the named insured, resident spouse, and any resident relative while occupying the covered motor vehicle, and to any other person legally occupying a covered motor vehicle.”
  • It has a time window. “Expenses must be incurred for services rendered within three years from the date of the accident,” although “nothing shall prevent an insurer from allowing a longer period of time.”

Whether a Policy Has It, and How Much

Insurers writing private passenger auto insurance in Georgia “shall file rates and forms for medical payments coverage for a limit of at least $2,000.00 but may file rates for higher or lower limits” (OCGA 33-34-3.1(a)). The same subsection adds that the filing requirement “shall not be construed as a requirement for the offering or quoting of medical payment coverages to insureds or as authority for the Commissioner to require the offering or quoting of such coverage.” A policyholder therefore has MedPay only if the policy includes it, in the amount the policy states.

Using MedPay Before the Injury Claim Is Resolved

Georgia’s reimbursement statute addresses exactly this sequence: benefits paid first, a recovery from the person at fault later. OCGA 33-24-56.1 defines a “benefit provider” to include “any insurer … which provides for payment or reimbursement of health care expenses” under a policy, and by its terms it governs reimbursement of benefits paid for medical expenses when the injured person later recovers from the person at fault:

  • Repayment only after full compensation. The benefit provider may require reimbursement from the recovery only if “[t]he amount of the recovery exceeds the sum of all economic and noneconomic losses incurred as a result of the injury,” and the reimbursement claim is “reduced by the pro rata amount of the attorney’s fees and expenses of litigation incurred by the injured party” (OCGA 33-24-56.1(b)). If a court determines that a settlement does not fully compensate the injured party, the benefit provider has no right of reimbursement (OCGA 33-24-56.1(c)).
  • No subrogation against the driver at fault. A benefit provider may not pursue subrogation for medical expenses or disability payments against the person at fault, and no defendant or liability insurer may put the reimbursing insurer on a settlement check as a copayee (OCGA 33-24-56.1(e)).
  • No withholding of benefits to force repayment. No benefit provider may reduce what it owes under “liability, uninsured motorist, disability, medical payments, or other benefits” as a setoff against a reimbursement claim, or “withhold or set off insurance benefits as a means of enforcing a claim for reimbursement” (OCGA 33-24-56.1(f)).
  • Notice before settlement or trial. A person pursuing the claim against the party at fault must notify any benefit provider believed to have paid benefits for the injury, by certified mail or statutory overnight delivery, at least ten days before a settlement is completed or a trial begins, and the notice must ask for an itemization of what the provider seeks (OCGA 33-24-56.1(g)).

For example, imagine that a passenger’s MedPay benefits paid $5,000 of hospital bills, and the passenger later settles with the at-fault driver for less than the full value of all losses. Under subsection (b), the MedPay insurer may seek reimbursement only if the recovery exceeds all economic and noneconomic losses, so a settlement that falls short of full compensation leaves it nothing to recover; under subsection (c), the insurer may seek a declaratory judgment on that question. Had the settlement exceeded all losses, the reimbursement claim would still be reduced by a pro rata share of the attorney’s fees and expenses.

If the MedPay Insurer Refuses to Pay

For the policyholder, MedPay is coverage under the policyholder’s own policy, and the statute on refusals to pay a covered loss applies. If an insurer refuses to pay a covered loss within 60 days after the policyholder’s demand and the refusal is found to be in bad faith, the insurer is liable, in addition to the loss, for up to 50 percent of its liability for the loss or $5,000, whichever is greater, and reasonable attorney’s fees (OCGA 33-4-6(a)).

Frequently Asked Questions

How does a jury’s verdict affect what the MedPay insurer can claim?
At trial, the jury may allocate the amounts paid among the categories of damages the plaintiff actually sought, and that allocation is conclusively presumed reasonable (OCGA 33-24-56.1(d)).

What if the policy says the MedPay insurer gets repaid first?
A policy term cannot override the statute: “no policy or contract provisions for subrogation or reimbursement in conflict with this Code section may be enforced by a benefit provider with regard to claims or injuries” (OCGA 33-24-56.1(j)).

Does the bar on withholding benefits stop insurers from coordinating benefits?
No. The same subsection states that it does not prohibit the coordination of benefits between or among benefit providers (OCGA 33-24-56.1(f)).

Can the ten-day notice period be shortened?
Yes, if the designated recipient of the notice agrees, and another form of notice may also be used by agreement (OCGA 33-24-56.1(g)).

  • OCGA 33-34-2(1); OCGA 33-34-3.1(a)
  • OCGA 33-24-56.1(a)(1), (b), (c), (d), (e), (f), (g), (j)
  • OCGA 33-4-6(a)

Disclaimer

This article provides general information about medical payments coverage under Georgia law. It is not legal advice and does not create an attorney-client relationship. What a particular policy pays depends on its terms and limits, and repayment questions depend on the facts of the recovery. Anyone with a claim should review the policy and consult a licensed Georgia attorney promptly about the particular situation.

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