The 411 on 911 - Am I Covered in an Emergency?

Most people who have health insurance think they are covered for all emergency room visits or ambulance transportation. But the American College of Emergency Physicians suggests that the time to make sure of the limitations of your health insurance policy is long before you need to dial 9-1-1. They recommend you check your health insurance policy, consult with your benefits advisor, or insurance agent to know exactly what you're covered for in the event of an emergency before you need it.

First up the ACEP says to be clear on the deductibles or copays on your policy. Many policies include copays for emergency care, or need to already have had the deductible requirement met, before paying for a trip to the ER. While the very definition of Emergency Care means that you usually will not have prior notice of the need for it, unfortunately many heath insurance plans require prior authorization for anything other then immediately life threatening emergency care. How a given healthcare plan defines "life threatening" differs form policy-to-policy and State-to-State, so again it is best that you are sure of the details of your policy, before you need to call an ambulance. Even plans that do not require prior authorization for ER treatment, may require that you notify them within 24 hours of admission to an ER, or they may not pay the bill. As an organization ACEP is lobbying to enact legislation that establishes a "Prudent Layperson" standard for health insurance plans regarding consideration of payment for "life threatening" emergency visits, based on a persons chief complaint and not the final diagnosis by the physician. In other words if a person calls 911 for chest pains, as ACEP suggests they should, and later the doctor diagnoses them with a non-life threatening condition, such as indigestion, they should not be penalized with non-payment by their insurance carrier for showing sound medical judgment.

The ACEP stresses that it is extremely important to know if your policy will pay for trips to any ER, or only specific ones. If it is only specific "in network" hospitals it is critical to know what and where they are before a crisis occurs so that you can direct your care to the proper facility. If you do need to go "out of network" because you are on vacation, or in a life threatening situation that necessitates transport to the nearest hospital, know what your out of pocket expenses will be.

If you feel that your insurance company has wrongfully denied payment of an emergency claim, you do have the right to appeal. You can appeal directly to the insurance company, or if you policy is provided 100% by your employer it is regulated by the US Department of Labor, and you can take your complaint there. And finally you can appeal to your States Department of Insurance.