New Jersey Administrative Code › Title 11 - INSURANCE › Chapter 4 - ACTUARIAL SERVICES › Subchapter 42 - GROUP LIFE, GROUP HEALTH AND BLANKET INSURANCE: GENERAL STANDARDS FOR CONTRACT PROVISIONS › Appendix - Appendix

Current through Register Vol. 56, No. 14, July 15, 2024
BENEFITS PAYABLE FOR AUTOMOBILE RELATED INJURIES
1. Definitions.
"Automobile Related Injury" means bodily injury sustained by an insured as as result of an accident while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an object propelled by or from an automobile.
"Allowable Expense" means a medically necessary, reasonable and customary item of expense covered by this (policy/certificate) or PIP at least in part as an Eligible Expense.
"Eligible Expense" means that portion of expense incurred for treatment of an injury which is covered under this (policy/certificate) without application of deductibles or copayments, if any.
"Out-of-State Automobile Insurance Coverage" or "OSAIC" means any coverage for medical expenses under an automobile insurance policy other than PIP, as PIP is defined herein, including automobile insurance policies issued in another state or jurisdiction.
"PIP" means personal injury protection coverage (specifically those provisions for medical expense coverage) provided as part of an automobile insurance policy issued in New Jersey.
2. Application of this section.
When expenses are incurred as the result of an Automobile Related Injury, and the injured person has coverage under PIP or OSAIC, this section will be used to determine whether this (policy/certificate) provides coverage that is primary to such coverage or secondary to such coverage. It will also be used to determine the amount payable if this (policy/certificate) provides primary or secondary coverage.
3. Determination of primary or secondary coverage.
This (policy/certificate) provides secondary coverage to PIP unless health coverage has been elected as primary coverage by or for the person covered under this (policy/certificate). This election is made by the named insured under a PIP policy and affects that person's family members who are not themselves named insureds under another automobile policy. This (policy/certificate) may be primary for one covered person, but not for another if the persons have separate automobile insurance policies and have made different selections regarding primacy of health coverage.
This (policy/certificate) is (primary/secondary) to OSAIC. (However, if the OSAIC contains provisions which make it secondary or excess to the policyholder's Plan, then the policyholder's Plan will be primary.) Omit if the policyholder's Plan is elected as primary coverage.
(If the policyholder's Plan is one of several insurance plans which provide benefits to the insured and are primary to automobile insurance coverage, then the rules as provided in the Coordination of Benefits section of this (policy/certificate) shall apply.) Omit if policyholder's Plan does not contain a COB provision.
If there is a dispute as to whether the policyholder's Plan is primary or secondary, this (policy/certificate) will pay benefits as if it were primary.
4. Benefits we will pay if the Plan is primary to PIP or OSAIC.
If the policyholder's Plan is primary to PIP or OSAIC, this (policy/certificate) will pay benefits payable on eligible expenses in accordance with the terms provided in this (policy/certificate).
5. Benefits we will pay if the Plan is secondary to PIP.
If the policyholder's Plan is secondary to PIP, the actual benefits payable will be the lesser of: (i) the remaining uncovered allowable expenses after PIP has provided coverage after application of deductibles and copayments, or (ii) the actual benefits that would have been payable had the policyholder's Plan been providing coverage primary to PIP.
6. Medicare.
To the extent that the (policy/certificate) provides coverage that supplements coverage under Medicare, then the policyholder's Plan can be primary to automobile insurance only insofar as Medicare is primary to automobile insurance.