Calculator inputs
Advanced options includedExample data table
| Scenario | Total Claimed | Deductible | Coverage | PIP Pays | Out-of-Pocket |
|---|---|---|---|---|---|
| Minor injury | $2,150.00 | $500.00 | 80% | $1,320.00 | $830.00 |
| Clinic + rehab | $5,850.00 | $1,000.00 | 80% | $3,880.00 | $1,970.00 |
| Higher wage loss | $9,400.00 | $500.00 | 100% | $8,900.00 | $500.00 |
These are illustrative examples for learning and planning.
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Formula used
- Total Claimed = medical + wage loss + essential services + other.
- Eligible (by category) = max(0, category − non-covered allocation).
- Eligible Total = sum of eligible categories.
- Deductible Remaining = max(0, deductible − deductible met).
- Deductible Applied = min(deductible remaining, deductible base).
- After Deductible = eligible-adjusted − deductible applied (proportional, or medical-only).
- Category Pays = after-deductible category × coverage % (global or category-specific), then optional sublimit.
- PIP Pays (after cap) = min(sum of category pays, remaining policy limit).
- Copay = (pays × copay%) + copay flat, optionally capped.
- PIP Pays (final) = after cap/coordination − copay − fault reduction.
Coordination can reduce eligible amounts first or subtract third-party payments from insurer payment, depending on your selection.
How to use this calculator
- Enter claimed expenses across medical, wage loss, services, and other.
- Add non-covered amounts, or split them by category.
- Set deductible, deductible met, and how deductible applies.
- Choose global coverage or category-specific coverage rates.
- Add sublimits, copay, coordination, and fault reduction if needed.
- Press Submit to see results, graph, and downloads.
Deductible mechanics and what the numbers mean
This calculator models a common PIP flow: expenses enter as categories, exclusions are removed, a remaining deductible is applied, benefits are calculated by coverage percentage, and payments are capped by limits. With a $500 deductible and 80% coverage, an eligible $5,000 becomes $4,500 after deductible, then $3,600 payable before caps. If the deductible is waived, remaining deductible becomes $0, and benefits start at the eligible amount for cleaner forecasts.
Category inputs improve planning accuracy
Separating medical, wage loss, services, and other helps reflect real-world claim structures. If medical is $4,200 and wage loss is $1,600, medical represents 72.4% of a $5,800 two-category total. When a deductible is distributed proportionally, the medical share of a $500 deductible is about $362, leaving category totals closer to policy math. This helps compare category sublimits and different reimbursement patterns.
Limits and sublimits shape the final payment
A global limit sets the maximum total benefit for the claim period. If your limit is $10,000 and prior PIP paid is $2,500, the remaining cap is $7,500. Optional sublimits can restrict a category even when the global limit is high; for example, a $3,000 medical sublimit can bind if medical benefits exceed that amount. Try a second scenario with a lower global limit to see when the cap becomes binding.
Coordination, copays, and fault adjustments
When another payer contributes, you can model coordination two ways: reduce eligible amounts first or subtract the payer from the insurer payment. Copay options add realism: a 10% copay on a $4,000 insurer payment is $400, and a $25 flat copay becomes $425, optionally capped (e.g., $500 max). A copay maximum prevents cost-sharing from growing without bound.
Using scenarios to compare outcomes
Save multiple scenarios to see how changes affect out-of-pocket costs. A $250 non-covered amount increases your burden dollar-for-dollar. Increasing coverage from 80% to 100% can reduce out-of-pocket by up to 20% of the after-deductible eligible amount, until limited by caps, sublimits, or coordination rules. Use the history chart to monitor trends across treatment weeks and missed-work periods.
FAQs
1) What does “eligible” mean here?
Eligible is the claimed total after removing non-covered amounts (either as a single total or split by category). The deductible and coverage percentages apply to this eligible pool in the estimate.
2) Why can PIP pays be less than “coverage %” suggests?
The estimate applies caps: category sublimits (if set), then the remaining global limit after prior payments. Coordination, copays, and fault reductions can also lower the final insurer payment.
3) How is the deductible applied across categories?
If set to “all eligible,” the deductible is distributed proportionally to eligible category amounts. If set to “medical only,” it is applied only to the medical eligible amount, up to the remaining deductible.
4) Should I enter third-party payments as “reduce eligible” or “subtract from payout”?
Use “reduce eligible” if other payments typically reduce the covered expense base. Use “subtract from payout” if the other payer is credited against the insurer’s benefit. Choose the mode that matches your policy handling.
5) What is the difference between copay and deductible?
Deductible is the amount you must cover before benefits apply. Copay is a cost-share that can apply after benefits are calculated, reducing the insurer payment and increasing your out-of-pocket amount.
6) Are these results exact for every policy?
No. PIP rules vary by jurisdiction and policy language. This tool provides a structured estimate for planning and comparisons. Always confirm details with your insurer, adjuster, or policy documentation.