Benefits and Claim Procedures: Emergency Room Services

Your policy is likely to have separate pages describing the benefits for “Participating Provider Services” and “Non-Participating Provider Services”. As previously explained, participating provider services are subject to a calendar year deductible and non-participating provider services are subject to a Separate Deductible for Non-Participating Providers. Though the deductibles that apply are different, the description of the covered expenses themselves are nearly identical.

For purpose of our discussion, we will use sample wording for participating provider services. You can assume that the only difference between the sample wording we use and that for non-participating provider services is the amount of the deductible that is applied unless we tell you of some other difference.

An “emergency” is defined to be the sudden onset of a medical condition the evidence for which is acute symptoms of sufficient severity, including severe pain, such that the absence of medical attention could reasonably be expected to result in:

1. placing the patient’s health in severe jeopardy;
2. serious impairment to bodily functions; or
3. serious dysfunction of any bodily organ or part.

Oftentimes you have to make the decision on the spot without the assistance of any kind of medical expert. Then all you can do is apply a common sense standard of reasonableness.

This provision does not provide benefits for emergency treatment in an emergency care facility, an ambulatory surgical center, a facility that primarily terminates pregnancies, a doctor’s office or dentist’s office. It only provides benefits for emergency treatment in the emergency room of a hospital. Emergency treatment in one of the other facilities may be covered by some other provisions of the policy.

*Wording may vary from contract to contract and from state to state.

Case Studies: Emergency Room Services Example Situation

Case Study 1: John’s Emergency Room Visit

John, a 35-year-old individual, experienced sudden severe chest pain and difficulty breathing while at home. Concerned about his symptoms, he immediately rushed to the emergency room of a participating hospital. Upon arrival, John received emergency room services, including diagnostic tests, X-rays, and consultations with medical professionals.

The hospital also provided necessary medications and a registered nurse attended to his needs. John’s medical expenses incurred during the emergency room visit were covered by his insurance policy, subject to the applicable deductible.

Case Study 2: Sarah’s Surgical Emergency

Sarah, a 42-year-old woman, had an accident that resulted in a deep cut on her leg. Recognizing the severity of the injury, she visited the emergency room of a participating hospital. After assessing her condition, the hospital performed emergency surgery to repair the wound. The surgical procedure was promptly notified to the insurance company within the required timeframe. Sarah’s emergency room visit, surgical services, as well as any related diagnostic tests and supplies, were covered by her insurance policy, subject to the applicable deductible.

Case Study 3: Michael’s Pediatric Emergency

Michael, a 7-year-old child, fell while playing and injured his arm. Concerned about a possible fracture, his parents rushed him to the emergency room of a participating hospital. The hospital provided Michael with emergency room services, including X-rays, a consultation with a medical professional, and the necessary medical supplies, such as a cast for his fractured arm. Michael’s parents received coverage for the incurred expenses related to the emergency room visit, subject to the applicable deductible.