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Anthem’s Policy on Avoidable ER Visits: A Closer Look

emergency room at the hospital

Anthem is one of the leading providers of health insurance in California and the second-largest insurer in the country. Like many large insurance companies, Anthem has a history of using shady tactics to avoid paying out on claims that should rightfully be covered. In addition to blanket policies denying coverage for debilitating conditions by erroneously labeling the treatment as “cosmetic,” Anthem has landed in hot water for refusing to cover emergency room (ER) costs if Anthem decides after the fact that the visit was “avoidable.” Continue reading to learn about Anthem’s cruel ER policy, and call a dedicated Los Angeles health insurance benefits denial lawyer for assistance obtaining insurance coverage in southern California.

Anthem Denies Coverage by Claiming ER Visits Were “Avoidable”

Health insurance is meant to protect people in the event of an emergency. In many cases, an injury or illness might appear minor, or the severity may be unclear in the moment, but seeking emergency treatment can make the difference between losing a limb or even a life. Anthem does not adhere to this understanding of emergency treatment, however. Under their controversial “avoidable ER program,” Anthem claims the right to retroactively deny coverage if the company decides that the patient did not need ER treatment after all.

Anthem’s policy would kick in, for example, if a patient is experiencing heart palpitations or chest pain and goes to the emergency room. If it turns out that they were suffering from indigestion or anxiety instead of an impending cardiac episode, then Anthem would retroactively deny coverage for the ER visit. The patient would then be stuck with hundreds or thousands of dollars in medical bills, depending on the tests conducted and other aspects of the visit.

The danger with Anthem’s policy, in addition to its abject cruelty, is that it discourages patients from obtaining emergency care. If a patient is suffering serious gastrointestinal pain, for example, they may have appendicitis or another serious condition. They may also have a buildup of gas or some other condition that will resolve itself. The problem for patients is that they won’t know which it is until it is too late.

A 2013 study in The Journal of the American Medical Association found that symptoms between actual emergencies and non-emergencies overlap as much as 90 percent. Patients are not doctors, and they should not be expected to make difficult (if not impossible) self-diagnoses before seeing an actual medical professional. Patients faced with the threat of non-coverage, however, will do their best to avoid emergency room visits even when faced with emergency-like symptoms. Threatening not to cover visits that turn out not to be emergencies will lead to serious patient injury and death.

Anthem’s controversial policy has been in place for several years. They have added certain conditions or circumstances that will trigger coverage, but they have not repealed the policy entirely. Several lawsuits have been filed in various states attacking the policy, but as it stands, the policy persists. If you have been denied coverage for a medical visit because Anthem decided your visit was non-essential, talk to a zealous health insurance coverage denial attorney for assistance.

Seasoned Advice and Representation for Obtaining Health Insurance Benefits in California

If your health insurance claim has been unreasonably denied, or if you are dealing with other bad faith insurance issues in California, fight for the coverage you are owed with the help of the experienced and trial-ready Los Angeles insurance claim denial lawyers at Gianelli & Morris. Call for a free consultation at 213-489-1600.

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