Demand for Medical Payments

[Rob]

Scenario: A bar has an incident where one patron physically attacked another patron. The police are called and said patrons are taken away.

The policy excludes assault and battery coverage and the wording of the exclusion is such that it applies to medical payments as well.

The bar receives a letter from an attorney demanding insurance information stating their intent to collect from the medical payments portion of the policy in the amount of $10,000. The medical payments limit is $5,000. The patrons are not placing any blame on the bar.

The policy's "Duties in the event of an occurrence or claim" require the insured to report this. However, is he required to report something that is clearly excluded? Is it just the wise thing to do so that the insurance company can formally deny to the attorney.

Last, why do you think the attorney is suing strictly for the med pay (actual medical damages) instead of filing a lawsuit against the bar?

[Insismypassion]

My opinion is the attorney is just looking for easy money and since med pay does not require negligence be proven to collect (only that an incident happened), he wants to tap that well.

Since it appears to be excluded, and he ain't gonna get anything he's got to decide if it's worth his trouble to try to assert negligence on the part of the business. Unless there are mitigating circumstances, I don't think that well has any water either.

As far as notifying the carrier. If you are the agent for the carrier, it is your responsibility to notify them and let them investigate and deny. If you are the broker (representing the client) it it your duty to advise your client to follow the policy guidelines and report the claim.

Don't make the final coverage call - leave that to the insurance company. It would be a bad thing if the attorney got there ahead of you.

[gregcw]

Scenario: A bar has an incident where one patron physically attacked another patron. The police are called and said patrons are taken away.

The policy excludes assault and battery coverage and the wording of the exclusion is such that it applies to medical payments as well.

The bar receives a letter from an attorney demanding insurance information stating their intent to collect from the medical payments portion of the policy in the amount of $10,000. The medical payments limit is $5,000. The patrons are not placing any blame on the bar.

The policy's "Duties in the event of an occurrence or claim" require the insured to report this. However, is he required to report something that is clearly excluded? Is it just the wise thing to do so that the insurance company can formally deny to the attorney.

Last, why do you think the attorney is suing strictly for the med pay (actual medical damages) instead of filing a lawsuit against the bar?

Although there is the "assault & battery exlusion" I don't think that exclusion applies here, because the occurence was on their premises. The INSURED did not either "assault" or "batter" anyone. Because they were not liable, think the policy would pay up to the $5,000 limit on Medical Payments because that is really a "Good Will" coverage designed to keep the other party from suing.

Anyhow I'd still submit the claim 1. Because it is still an "occurence" and the attorney made it a "claim" and 2. to have the company take the monkey off MY back. Because of the police involvement I don't think it was necessary to report just the occurance.

[Rob]

Thanks. How does a payout on med pay affect the insured's ability to renew coverage?

[Insismypassion]

Thanks. How does a payout on med pay affect the insured's ability to renew coverage?

Provided there haven't been a rash of Med Pay claims, this should have very little effect. Again, the establishment is not admitting negligence (if any payment is made at all), so one won't be that big of a deal.

[shannonwells830]

Any accidents that happen in a bar that resulted an injury should be covered by the owner of the property that is why there is such thing as public liability insurance. This protects them against negligence claims being brought on to them.

[Claimsman]

Regarding "shannonwells830"'s comment, please note that most states are upholding the assault and battery exclusion, regardless of whether the A&B involved an insured or not. It is intended as an absolute exclusion regardless of who the participant is. As someone has already suggested, the demand for med-pay needs to be sent to the insurer for their action.

[Iowa Guy]

Why are companies providing such high med pay limits nowadays with the sue happy society we are in? I see "Enhancement endorsements" increasing med pay to $10,000 or even $15,000.

I like to exclude med pay coverage on retail type businesses that I insure. If guilty, we'll still pay but I don't want to be an open check book for every Tom, Dick and Harry and their blood sucking attorney, that walks through the door.

anyone see a problem with this? I understand the concept of "good will" but too many abuses are taking place.