Coverage is triggered by bodily injury caused by an accident on premises the named insured owns or rents or ways next to such premises or because of the named insured's operations, provided that the accident takes place in the coverage territory and during the policy period. In addition, expenses have to be incurred and reported to the insurance company within one year of the date of accident. Coverage is available regardless of fault. Several exclusions further define coverage, as discussed below.

Topics covered:

Insuring agreement

Trigger and other requirements

Exclusions

Insuring Agreement 

a. We will pay medical expenses as described below for "bodily injury" caused by an accident:

(1) On premises you own or rent;

(2) On ways next to premises you own or rent; or

(3) Because of your operations provided that:

(a) The accident takes place in the "coverage territory" and during the policy period;

(b) The expenses are incurred and reported to us within one year of the date of the accident; and

(c) The injured person submits to examination, at our expense, by physicians of our choice as often as we reasonably require.

b. We will make these payments regardless of fault. These payments will not exceed the applicable limit of insurance. We will pay reasonable expenses for:

(1) First aid administered at the time of an accident;

(2) Necessary medical, surgical, x-ray and dental services, including prosthetic devices; and

(3) Necessary ambulance, hospital, professional nursing and funeral services.

 Analysis

 The medical payments insuring agreement contains the insurer's promise to pay medical expenses for bodily injury caused by an accident. Bodily injury has the same meaning as elsewhere in the CGL coverage part: "bodily injury, sickness or disease sustained by a person, including death resulting from any of these at anytime." The requirement that the injury be "caused by an accident" is not elaborated on in the policy provisions, but is generally understood to mean that the event causing injury can be traced to a definite time and place, and that the injury was not expected or intended from the insured's or the injured person's point of view.

 To illustrate the latter point, say that the named insured is a merchant at whose going-out-of-business sale two customers disagree over who can buy the last pair of designer jeans in their mutual size. If one of the customers settles the argument by suddenly and without warning striking the other customer, the resulting injury will have been no accident from the viewpoint of the customer doing the striking. From the viewpoint of the injured customer, however, the injury will have been quite unexpected and unintended and therefore accidental. The fact that the customer was injured by an intentional act of another person should not stand in the way of medical payments coverage.

 This rule of policy interpretation is aptly expressed as follows in the North Carolina case of Nationwide Mut. Ins. Co. v. Roberts, 134 S.E.2d 654 (N.C. 1964): "When an insured is intentionally injured or killed by another, and the mishap is as to him unforeseen and not the result of his own misconduct, the general rule is that the injury or death is accidentally sustained within the meaning of the ordinary accident insurance policy and the insurer is liable therefore in the absence of a policy provision excluding such liability."

 The insuring agreement goes on to state that medical payments coverage applies to injuries that take place on premises that the named insured owns or rents; on ways next to such premises; or because of the named insured's operations. The third item makes it clear that coverage applies to accidents that occur away from the named insured's premises, as long as the injuries result from the named insured's operations. However, the coverage for accidents taking place on the insured's premises or on the ways next to them is broader than that which applies elsewhere, since there is no requirement, with respect to such premises, that the injury must result from the named insured's operations. If, for example, a child is injured while trespassing on the insured's grounds after the insured's regular business hours, and even if the injury results from something other than the insured's operations, such as the child tripping over his own toy, medical payments coverage can still apply to the child's injuries.

  Trigger and Other Requirements

 Another requirement set forth in the insuring agreement is that the accident must take place in the coverage territory and during the policy period. The meaning of coverage territory is discussed elsewhere in the Public Liability section of the Casualty & Surety Volume. The requirement that the accident must take place during the policy period in order for coverage to be triggered under that policy is essentially the same as the occurrence trigger that applies to coverage A of CGL coverage form CG 00 01, which requires that the bodily injury or property damage must occur during the policy period. The occurrence trigger applies to medical payments coverage even if the policy provides coverage A (liability) on a claims-made basis. Thus, there is always the possibility, when the insured's liability coverage is claims-made, that a medical payments claim and a liability claim arising out of the same accident could be covered under different policies of the insured.

 To illustrate, say that an injury occurs late in 2011. The injured person makes a claim in early 2012, after a renewal policy is in effect. Any medical payments claim will be covered under the 2011 policy, because the accident took place in 2011. However, a related liability claim first made against the insured in 2012 could be covered under the renewal policy that is in effect at the time of the claim, depending on the retro date.

 In order to be covered, expenses must be incurred and reported to the insurer within one year of the date of the accident. In previous medical payments forms, it has only been required that the expenses be incurred within the stipulated time period. Now, apart from the initial reporting of the accident, the expenses must be reported to the insurer within one year after the accident.

The insuring agreement also requires the injured person to submit to examination, by physicians of the insurer's choice, as often as the insurer reasonably requires. Of course, the insurance company agrees to bear the expense for such examinations.

 A statement that medical payments shall not exceed the applicable limit of insurance is also in the insuring agreement. The limit for medical payments coverage is an amount stated in the declarations that applies to each person. This coverage is also subject to the general aggregate limit of the policy. That is, if the general aggregate limit is exhausted by claims under coverages A or B of the policy, the insurer will have no further obligations under coverage C, even if no other medical payments claims have been presented during the policy period. (The products-completed operations aggregate limit has no applicability to medical payments coverage, simply because the medical payments coverage flatly excludes bodily injury within the products-completed operations hazard.)

 The types of medical expenses that the insurer will pay are listed in the policy as follows: first aid that is administered at the time of an accident; necessary medical, surgical, x-ray and dental services, including prosthetic devices; and necessary ambulance, hospital, professional nursing and funeral services.

 With the exception of the first item, the types of expenses listed as being covered are the same as in previous medical payments forms. The addition of the first item, concerning first aid expenses, seemed to be intended to compensate for the fact that the 1986 CGL coverage forms did not provide first aid coverage as a supplementary payment, a benefit that is provided in addition to policy limits under the 1973 general liability policy. In the 1986 CGL forms and in the current forms, first aid at the time of an accident is covered under medical payments only, and therefore subject to policy limits. However, should medical payments coverage be excluded (through endorsement CG 21 35 10 01), the policy's supplementary payments are amended to include expenses incurred by the insured for first aid to others at the time of an accident for bodily injury to which the insurance applies.

 Exclusions