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Emergency room visit FAQ for visitors insurance in USA
Q: I took my mother to the hospital and she had multiple procedures done, x-rays, blood work etc. and ended up being admitted. Why was the x-ray and lab work that was done in the Emergency Room denied saying "per injury/illness maximum has been reached"?
A: You would need to refer to your policy's certificate wording to verify the maximum amount allowed for Emergency Room visits. Keep in mind that the amount listed is for all services that are provided, including but not limited to the room itself, lab work, diagnostic x-rays, the doctors bill etc. You will be responsible for all charges that exceed the amount listed in the certificate wording.
Q: But my certificate wording has a different amount listed as the maximum amount payable for diagnostic x-rays and labs, why are they not paying that amount?
A: If the diagnostic x-rays and labs were performed as part of the Emergency Room visit, the insurance payment will be based on the maximum amount allowed for Emergency Room visits. If you were to have lab work/diagnostic x-rays done at a free standing facility such as Quest Diagnostics or LabCorp because a physician prescribed them, the maximum allowed payment would reflect the amount you are seeing in your certificate wording under Outpatient diagnostic x-rays and labs.
Q: My mother had to have a CT scan done because she fell and hit her head and now the insurance company is denying the claim. Wouldn't this be considered as diagnostic testing, why is it not being paid?
A: If the CT scan was performed before she was admitted it is likely the maximum benefit for the Emergency Room and all charges incurred therein was reached. The other possibility could be whether or not pre-certification was obtained for the CT scan, you will want to refer to your plans certificate wording for details on Emergency Room treatment and pre-certification requirements.
Q: My mother was experiencing some chest pain on the left side and numbing in her left arm. I called the doctor and they told me to take her to the Emergency Room because she might be having a heart attack. When we got to the hospital they said she was not having a heart attack and discharged her and now the insurance company is not paying her claims. I did what the doctor told me to do, so why is the insurance company not paying the claims?
A: Please refer to your policy's certificate wording to find out the rules related to the use of the Emergency Room. Most fixed coverage plans have penalties and or will not pay at all for the use of the Emergency Room if it is not followed by admission.
Q: Will I still get the Network Negotiated Fees if the insurance company does not pay the claim? These bills are very expensive and I cannot afford to pay them.
A: You will not be given the Network Negotiated Fees. Network Negotiated Fees are only applied to the eligible expenses that are payable by the insurance company.
Q: My father had headaches for 2 days because his blood pressure was high. He ended up having a stroke and was later admitted into the hospital. The insurance company has denied the claim as a pre-existing condition but I purchased a plan that allows for the acute onset of a pre-existing condition, why is it still being denied?
A: The definition of an acute onset of a pre-existing condition states that treatment MUST be obtained within 24 hours, you stated that the symptoms were present 2 days prior to the hospital admission, therefore, the claims will be denied as a pre-existing condition and not allowed for payment as an acute onset.
Q: Will ER visits be covered? If something happens to my mom I want assurance that I can take her to the Emergency Room and it will be covered. You never know what could happen, right?
A: Coverage for an emergency room visit may be different depending on the plan you purchase. Some fixed coverage plans state, "No coverage if the ER visit for an illness does not result in direct hospital admission" while others state, "No coverage if ER visit is not of an emergency nature". Keep in mind that it is not based on what you think is an emergency, it is based on the doctor's document. For example, a person may be having some chest discomfort and you may think it is a heart attack but if the doctors determine they are not having a heart attack but is suffering from say, indigestion or gas, this would result in a denied claim with no payment because it was not an emergency.
Emergency room visits are very expensive and should only be used in true emergency situations. While comprehensive plans typically pay for emergency room visits, a penalty may be given if the ER visit is not documented as being emergent in nature or does not result in direct hospital admission. For example, Atlas products will apply a $200 penalty, Patriot Products will apply a $250 penalty, and Liaison products do not provide any coverage.
It is important that you understand how your plan works, especially for emergency room visits. We also advise utilizing a primary care physician or urgent care facility for non-emergency related illnesses and injuries to prevent denials and/or penalties being assessed. If an illness is severe enough to warrant hospital admission or if there is an injury that requires an emergency room visit, it may be covered based on the policy you purchased.
Disclaimer: The information within this article is intended as a broad summary of benefits and services and is meant for informational purposes only. The information does not describe all scenarios, coverages or exclusions of any insurance plan. The benefits and services of an insurance plan are subject to change. This is not your policy/certificate of insurance. If there is any discrepancy between the information in this article and the language of your policy/certificate wording, the language of the policy/certificate wording will prevail.