Tuesday, December 4, 2012

Can a health insurance company deny emergency medical coverage based on the final diagnosis


Can a health insurance company deny emergency medical coverage based on the final diagnosis?
I went to the emergency room for symptoms suggesting a life-threatening illness. It turned out I did not have a life-threatening illness and the ER doctor diagnosed something much less severe. However, now my health insurance company is refusing to pay for the emergency room fee based on that diagnosis. This seems unethical to me. My symptoms indicated an emergency, so I went to the hospital. Just because it turned out I didn't actually have a condition requiring emergency medical attention, doesn't mean my health insurance company has the right to deny me coverage.
Insurance - 7 Answers
Random Answers, Critics, Comments, Opinions :
1 :
Your insurance company should pay as long as you have emergency room coverage. There shouldn't be a problem with that, call your insurance company again and maybe your agent can help you.
2 :
Yes. They cover what they cover. Most of the time, if you don't get admitted, you pay a way lot more for your overreaction. They aren't denying you coverage - if you look to your policy, it will say, "emergency room visits only covered if you are admitted" or some such. Blame the doctor, or blame yourself, for not having a life threatening condition. The policy is what it is - the coverage is clearly worded. Read it over, so NEXT time you don't have any surprises.
3 :
Most state insurance laws use "prudent layperson" criteria. Meaning...if a "prudent layperson" (i.e. - a reasonable ordinary citizen) would consider the circumstances as an emergency, then the insurance company should process the claim as an emergency. By the way...hospital claims specify the diagnosis you presented to the ER with, in addition to your final diagnosis. So, the insurance company should be aware of the symptoms you presented to the ER with, in addition to your final diagnosis. Its hard to say what happened in your situation, without knowing what symptoms you had that made you feel like it was an emergency. But you should at least be able to appeal with an explanation of why you felt it was necessary to seek emergency care. But insurance companies can have tiered benefits ("emergency" use of the ER, and "non-emergency" use of the ER...based on whether or not a reasonable person would consider your situation an emergency). You can either have a reduced benefit for non-emergency situations, or no benefit at all.
4 :
Read your insurance under emergency room expenses covered. You'll find you're covered. Insurance companies are dogs; they'll tell you it's denied and if you swallow it, they saved the money. If you prove them wrong, they'll shrug and say "sorry, honest mistake" and pay up.
5 :
~~You can try and have the doctor who gave the billing diagnoses code, write a letter to the insurance company stating that the symptoms while not a serious diagnose, appeared to need emergency treatment. This may help them reverse the decision. Otherwise, they can hold you responsible if your policy had strict guidelines on ER visits.~~
6 :
Potentially. Insurance companies are trying to keep people out of emergency rooms that don't belong there. I would be surprised if they've denied the whole claim. Usually they'll just make you responsible for more of the bill. In other words it wouldn't be odd to have a $250 copay for an emergency room that is waived if you're admitted -- accident being treated different than illness of course.
7 :
I'm not an expert on this, however I would suggest you take a tour here http://www.HealthInsuranceIdeas.info/free-online-health-insurance.htm ,there are expert's tips there.



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Posted by Health Insurance at 8:09 PM