- Medical expenses
- Lost income or wages and
- Burial and funeral expenses
The type of expenses that are covered and the amounts that insurers will pay vary from state to state, so it's important to know your state's no-fault laws and the specific language of your policy.
Limitations on BenefitsIn some states, an insurer can limit the amount of PIP benefits that will be paid to an insured victim. The limitations can be based on time or the language in the insurance policy.
Some no-fault laws specify the period of time during which no-fault benefits will be paid. For example, in some states, all no-fault payments stop after two years, which is measured from the date of the loss, which is usually the date of the accident.
Other states might limit only some types of payments, like lost wages, to a certain period, while other states might limit the amount. For example, the victim might receive 90% of his or her lost wages in the first year after the accident, but then a smaller percentage in years two and three, and so on.
Some no-fault laws let insurers specify the amount of PIP benefits that are payable - a " benefits ceiling." For example, some statutes allow a limit with a specific dollar amount for medical expenses, like $100,000, while some statutes allow "unlimited" medical expenses, but only if the they are "reasonable and necessary."
No state with no-fault car insurance allows unlimited benefits for wage losses.
Most states allow insurers to "set-off," or reduce, the amount of no-fault benefits by the amount received by the injured insured from other sources. The most common set-off is for workers' compensation benefits paid to the insured victim.
Some states allow set-offs for Social Security disability payments and Social Security retirement benefits, while most states do not allow a set-off for Medicare and Medicaid benefits.
Other insurance coverage can also work to limit or reduce no-fault benefits in some states. Benefits that a victim receives from one insurance policy, such as accident insurance, can lower the benefits owed by the no-fault insurer.
Medical ExpensesTo recover medical expenses, the insured victim has to show that the medical condition or problem was connected to his or her use of a motor vehicle. Most courts use a test that mixes being at or near the site of the accident and strict proximate cause in tort - showing a direct and near-immediate connection between the injury and the accident.
For example, a victim usually will be denied medical expenses that resulted from an accident where he exited his car, took several steps away from the car, tripped, and fell on the curb of a parking lot, breaking his leg. But, a driver who was injured when she stumbled into a hole in the driveway immediately after she exited, "or "alighted," from her car, usually will recover medical expenses.
In addition, to be recoverable, most no-fault laws require that the medical expenses be "reasonable and necessary." This issue arises most often when the insurer questions the amount of medical expenses or the type of medical treatment, that is, the insurer thinks he expense is too high, or that the victim could have obtained other, less expensive treatment.
Under some PIP laws, there is a presumption that medical expenses are reasonable and necessary when certain evidence is presented, such as a medical bill. Other laws specify what is reasonable and necessary by setting the charges for diagnosis, treatment and rehabilitation of injured persons, or by adopting the fee schedule and guidelines found in the state's workers' compensation laws and regulations.
Work Loss BenefitsTypically, no-fault statutes provide only for the recovery of wages actually lost, as opposed to also providing for lost earning capacity - the future ability to earn.
As a general rule, in order to qualify for work loss benefits, the injured person must have been employed or employable at the time of the injury and he or she must have suffered an actual or real loss of earnings, that is, the loss is easily measured and certain. Remember too that this type of benefit might only be payable for a certain amount of time after the accident.
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