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Emergency room visit coverage in visitors insurance for fixed coverage plans


The Emergency Department, also commonly referred to as the "Emergency Room" is where you should go to seek treatment for life threatening/urgent medical care. This article will help you understand the charges you are likely to receive during a visit to the Emergency Department. Regardless of what plan you purchase, it is important that you understand when you should utilize the hospital, and how your plan will pay for the charges incurred there. A hospital's outpatient department, also referred to as the Emergency Room (ER), should only be used in the event of an emergency which is considered to be a life threatening, urgent situation. If your injury/illness is not life threatening you should consider seeking treatment from a doctor's office or an urgent care facility. While the treatment may be the same, the cost is significantly less.


In this article, we will focus on the fixed coverage plans. These plans offer very little coverage and have strict requirements which must be met before the insurance company will pay the fixed amount for Emergency Room charges. Fixed coverage plans pay a fixed amount for each procedure and you are responsible for the rest. We will use the Visitor Secure plan with a $50,000.00 policy max and a $100.00 deductible as an example to help explain how a fixed coverage plan works in regards to outpatient Emergency Room services. Please keep in mind that you are responsible for your deductible before your plan will pay the fixed amount associated with a particular service (the deductible is per injury/illness in most fixed coverage plans).


In the event that you find yourself in a situation where you feel you should visit an Emergency Room for treatment, you will first be examined by doctors in the Emergency Room. During the initial treatment, depending on your injury/illness, you are likely to have multiple procedures done (diagnostic x-rays, lab services, surgery, etc.). All services are separate, meaning you will receive bills related to each service; for example, you may receive a bill from the doctor, another bill from the x-ray technician, a bill from the Emergency Department for the use of the room you were in, the medication they supplied to you and the list can go on, and on. The fixed coverage plans will ONLY pay the fixed amount listed in the schedule of benefits for ALL charges incurred in the Emergency Room.


For example, the Visitor Secure plan with a $50,000.00 policy maximum will only pay up to $355.00 (per injury/illness) for the use of a hospital Emergency Room and ALL EXPENSES INCURRED THEREIN. This means that regardless of how much everything totals up to for the room, the medication, the x-rays, the attending physicians charges, surgery (intensive or not), etc. the policy is only going to pay up to the fixed amount of $355.00 (this amount may be different depending on the plan and policy maximum you choose) and you are responsible for the remaining balance. The Visitor Secure plan indicates that if you are seen for an illness, you must be admitted in order for the Emergency Department charges to be paid. What this means is, if you go the Emergency Room for treatment related to an illness (Food poisoning, the Flu, Pneumonia etc.) and you are not admitted, the plan will pay NOTHING towards the bills related to that Emergency Room visit. If you go to the Emergency Room for an injury or accident (broken leg, dog bite etc.) the charges will be allowed for payment.


For example, if you go to the Emergency Room for a broken leg the plan will allow for payment regardless of whether or not you are admitted into the hospital. If you go to the Emergency Room because you have the flu and you are not admitted into the hospital the plan will pay NOTHING, and you will be responsible for all charges.


Example 1:

Let's say you were seen in the Emergency Room for an illness and you are admitted, in this instance the Emergency Department charges would be allowed for payment, (as long as it is an eligible expense) the payment would be as follows:


If the total charges add up to $1,500.00, you would be responsible to pay your deductible before the insurance company will pay anything which for this scenario is $100.00 (The Visitor Secure plan offers choices of $0, $50 and $100, if you are over age 70, you have the option to choose a $100 or $200 deductible). The plan would then pay up to the $355.00 which is the fixed amount related to the policy maximum of $50,000.00, after your $100.00 deductible the insurance company is actually only paying $255.00 ($355.00 - $100.00 = $255.00) and you would be responsible for the difference which would be $1,145.00. Your total patient responsibility would be $100.00 (your deductible) + $1,145.00 (remaining balance after insurance payment of $255.00) = $1,245.00.


Example 2:

Let's say you visited the Emergency Room for an illness and you were not admitted, the Emergency Room visit would not be paid.


If the total charges added up to $1,500.00 you would be responsible for the full amount of $1,500.00.


Note: The Visitor Secure plan does not participate in a PPO network, but if your plan does please understand that Network Negotiated Fees are only applied to charges that the insurance company considers payable.


It is important that you understand how your plan works, for more details on how your plan works please refer to your policy's certificate wording, brochure and benefits details. Emergency Room visits whether outpatient or inpatient are very expensive so if treatment can be provided at a doctor's office or an urgent care facility it is in your best interest to seek treatment there. While the decision is always yours, it is important that you understand how your plan works before the charges are incurred.



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.