Is Pennsylvania a No-Fault State? How First-Party Benefits Work

Is Pennsylvania a no-fault state?

Pennsylvania is a choice no-fault state: every auto policy on a registered car must include at least $5,000 in first-party medical benefits that pay regardless of fault (75 Pa.C.S. § 1711), but you still keep the right to sue the at-fault driver, to a degree that depends on whether you chose limited tort or full tort. Property damage to your car is not part of the no-fault system and is still claimed based on fault.

People often call these benefits PIP, short for personal injury protection. Pennsylvania's statute calls them first-party benefits, which it defines as medical benefits, income loss benefits, accidental death benefits and funeral benefits (§ 1702).

What first-party benefits pay

The required minimum is a $5,000 medical benefit. Insurers must also offer additional first-party benefits for purchase (§ 1712). What you actually have depends on what you bought, so your declarations page is the place to start.

• Medical benefits: reasonable and necessary treatment and rehabilitation, including hospital, surgical, psychological, chiropractic, physical therapy, ambulance, prescription and prosthetic costs
• Income loss benefit (optional): 80% of actual lost gross income, starting after five working days have been lost
• Accidental death benefit (optional): paid to the personal representative if the crash causes death within 24 months
• Funeral benefit (optional): funeral and burial or cremation expenses when death results within 24 months
• Extraordinary medical benefits (optional): medical benefits above $100,000

Which policy pays first

Pennsylvania sets a strict order of priority for first-party benefits (75 Pa.C.S. § 1713). You look first to the policy on which you are a named insured. If you have none, the next source is a policy covering you as an insured, such as a spouse's or a parent's policy in your household. If neither exists, the policy on the vehicle you were riding in pays. A person who was not in a vehicle, such as a pedestrian, can claim against the policy on any vehicle involved in the crash.

This order holds even when the other driver was clearly at fault. Your own insurer pays your medical bills first, and the at-fault driver's insurer handles the injury claim that goes beyond those benefits.

If no policy applies at all, Pennsylvania's Assigned Claims Plan may pay up to $5,000 in medical benefits to an eligible Pennsylvania resident injured in a crash in the state who does not own a vehicle required to be registered (75 Pa.C.S. §§ 1752, 1753). It does not pay income loss or death benefits.

Motorcycles are treated differently

The $5,000 required medical benefit in § 1711 expressly excludes motorcycles, motor-driven cycles and motorized pedalcycles, and so does the requirement to offer the optional benefits in § 1712. A rider's first-party coverage depends on what the motorcycle policy includes and whether the rider is covered as an insured under a household auto policy. Riders also cannot use the Assigned Claims Plan when they were operating or riding a motorcycle involved in the crash (§ 1752). If you were hurt on a motorcycle, have your policies reviewed before assuming anything is covered.

How and when first-party benefits must be paid

Benefits are overdue if they are not paid within 30 days after your insurer receives reasonable proof of the amount. Overdue benefits carry interest at 12% per year, and if a court finds the insurer acted unreasonably in refusing to pay, the insurer must also pay a reasonable attorney fee (75 Pa.C.S. § 1716).

Medical providers are limited in what they can charge for treatment covered by these benefits. They generally cannot accept more than 110% of the applicable Medicare-based amount, or their usual charge if that is lower (75 Pa.C.S. § 1797).

Your insurer can challenge treatment as unnecessary through a state-approved Peer Review Organization (§ 1702). A peer review denial is one of the common reasons medical benefits stop. It can be contested, and your treating doctors' records are the core of that challenge.

How first-party benefits fit with your injury claim

Benefits your own insurer pays under first-party coverage cannot be recovered again from the at-fault driver (75 Pa.C.S. § 1722). Your injury claim against that driver focuses on losses beyond those benefits: medical bills above your limits, income loss you did not have coverage for, and, depending on your tort option, pain and suffering.

Pennsylvania also bars your auto insurer from being reimbursed out of your injury recovery for first-party benefits it paid (§ 1720). That protects the money you recover from the other driver.

Your tort election matters just as much. Under limited tort, pain-and-suffering damages are barred unless your injury is a serious injury or an exception applies. Our guide to limited tort vs. full tort explains each exception.

First-party benefits are not the same as UM and UIM coverage

First-party benefits pay set categories of expenses no matter who was at fault. Uninsured and underinsured motorist coverage works differently: it pays what you could have recovered from an at-fault driver who had no insurance or not enough. Insurers must offer UM and UIM coverage, and a rejection is only valid on the exact signed form the statute requires (75 Pa.C.S. § 1731). If you were hurt by an uninsured or hit-and-run driver, both coverages can matter, so check your declarations page for each one.

Who pays for car damage in Pennsylvania

No-fault benefits cover injuries, not vehicles. Damage to your car is paid either by the at-fault driver's property damage liability coverage, which must be at least $5,000 under Pennsylvania's minimum financial responsibility (§ 1702), or by your own collision coverage if you bought it.

Deadlines for first-party benefits and injury claims

If first-party benefits have not been paid, a lawsuit to collect them must generally be filed within four years of the accident. If they have been paid, a suit for further benefits must generally be filed within four years of the last payment. For minors, the four years run from the date the child turns 18 (75 Pa.C.S. § 1721).

The deadline for an injury lawsuit against the at-fault driver is shorter: generally two years from the crash (42 Pa.C.S. § 5524). Claims involving a government agency, including SEPTA, generally require written notice within six months (42 Pa.C.S. § 5522). Your policy may also require prompt notice of a claim.

Getting help with a first-party benefits problem

If your medical benefits were cut off, your income loss claim is stalled, or you are not sure which policy should pay, Warren I. Siegel can review it with you. He has practiced in Pennsylvania since 1992 and handles car accident claims across Delaware County and West Philadelphia from our Upper Darby office.

Our fee is 100% contingency: no attorney fee unless we recover, the firm advances all case costs, and those costs are repaid only from a recovery. Call (267) 412-4601 or send the free case review form.