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What if the Insurance Company Says Your ER Visit Wasn’t an Emergency?

Emergency room in hospital and nurses are working to help emergency patients.

Insurance companies don’t like ER visits because they are much more expensive than a scheduled doctor visit or even a trip to urgent care. Regardless, emergency departments exist for a reason. People do have medical emergencies, and emergency room physicians are specially trained in emergency medicine to deal with any kind of emergency, including diagnosing distressing conditions that may or may not turn out to be emergencies and treating them accordingly.

When you are feeling ill, you only know what your symptoms are, not what your condition is. You aren’t a doctor, after all. What you are experiencing might turn out to be an emergency and it might not. But if you are experiencing severe pain or other troubling symptoms, then you believe you have a medical emergency, regardless of how serious the condition turns out to be. Yet insurance companies have been known to turn down claims for emergency care when the visit did not prove to be an emergency after the fact. This isn’t fair, and it goes against California law.

Read below to learn what California law says about insurance coverage for emergency services and what to do if the insurance company denies your claim for a trip to the ER. For help fighting a wrongfully denied claim or bad faith insurance practices that deny you the coverage you are entitled to and cause you harm, contact Gianelli & Morris to speak with an experienced and dedicated California insurance law attorney.

Was It an Emergency? Objective Versus Subjective Standards in the Law

To be sure, emergency rooms should only be used for emergencies, but what constitutes an emergency? Insurance companies want to evaluate the visit after the fact and see whether the person who entered the ER with severe gastric pain had appendicitis requiring immediate surgery or constipation that could be treated with stool softeners. If it turns out the person did not have an actual emergency, they’ll deny the claim, sticking the patient with thousands of dollars in hospital bills. But this approach misses the point; the patient was experiencing pain and discomfort severe enough to warrant going to the ER, not knowing what the cause of the distress was. So long as their belief that a trip to the ER was warranted was reasonable, should the insurance company be allowed to deny the claim?

The Centers for Medicare and Medicaid Services (CMS) managed care regulations define an emergency as a medical condition that manifests itself “…by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in the following:

(i) Placing the health of the individual (or, for a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.

(ii) Serious impairment to bodily functions.

(iii) Serious dysfunction of any bodily organ or part.”

The CMS definition is an objective “reasonable person” standard that asks whether a “prudent layperson” with “average knowledge of health and medicine” would “reasonably expect” they were having an emergency. California, however, does not use this definition. Instead of an objective, “reasonable person” approach, California law relies more on the patient’s subjective belief that they are having an emergency. According to section 1371.4 of the California Health and Safety Code, coverage of ER visits can only be denied if it is shown the patient “did not require emergency services care and the enrollee reasonably should have known that an emergency did not exist.” The California rule does not rely on a fictitious “prudent layperson” but instead asks whether the patient had a reasonable belief that an emergency existed.

Despite the language of California law that clearly differs from the “prudent layperson” standard, many insurance companies operating in the state continue to utilize a definition that mirrors the “prudent layperson” standard of the Medicare and Medicaid rules. Anthem Blue Cross, for instance, utilizes a form of this “prudent layperson” standard. While a “Member News” page on Anthem’s website starts with “Always call 911 or go immediately to the ER if you think it’s a life-threatening situation,” the article quickly makes it clear that claims for ER services will be reviewed using the “prudent layperson standard” and potentially denied. The webpage does not define the prudent layperson standard in any way except to note that “A prudent layperson has an average knowledge of health and medicine,” echoing the Medicare definition. The page does say that the review “will take into consideration the symptoms that brought you to the emergency even if the diagnosis turned out to be a non-emergency ailment.”

This Member News article is dated August 17, 2017, a couple of years before Anthem was called onto the carpet at the California Department of Managed Health Care (DMHC) for incorrectly using the “prudent person” standard to analyze and deny ER claims (see Report Blasts Anthem for Denying ER Service and Treatment, posted October 31, 2019). Yet that page is still accessible on Anthem’s website today, touting the prudent layperson standard that DMHC specifically told them was wrong.

Out-of-Network ER Visits Are Covered by Medi-Cal

If you are on Medicaid and are on a Medi-Cal plan like Anthem Blue Cross, Health Net, or Blue Shield Promise Health Plan, it’s important to know that emergency room trips are one of the rare areas where your visit should be covered even if you select a hospital that is not in your network. The standard HMO prohibition against covering out-of-network facilities does not apply to the ER. If you go to a hospital for emergency care that isn’t in your network, Medi-Cal might charge you a higher copay for a non-emergency use of the ER, but you should not get stuck with a denied claim and hospital bills in the tens of thousands of dollars.

Contact Gianelli & Morris for Help With Denied Coverage for Emergency Room Visits in California

If your insurance company denied your claim for emergency services because they say your reason for the visit wasn’t an emergency, it may be worthwhile to consult with an attorney to evaluate your claim. It could well be the insurance company is unlawfully denying your claim and leaving you to foot a hospital bill in excess of ten thousand dollars when what you actually owe is only a fraction of that amount. In California, call Gianelli & Morris in Los Angeles at 213-489-1600 to speak with our skilled and knowledgeable California bad faith insurance lawyers. We work every day helping policyholders whose claims were wrongfully denied.

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