Health insurance is intended to cover you in case of any medical emergency. Included in this are doctor visits, hospital stays and if needed, trips to the emergency room. Consumers who have health insurance shouldn’t have to second guess their choice to go to the emergency room if they find themselves ill or injured.
Heath insurers are denying ER visits. One such case happened in August of 2017 when a woman named Brittany Cloyd went to the ER after having debilitating pains in her abdomen. Cloyd was diagnosed with ovarian cysts, treated with pain medication and sent home.
A few weeks later, Ms. Cloyd received a bill over $12,000 for the ER visit. Her health care provider, Anthem Blue Cross, sent a letter with her bill stating that her visit did not meet their definition of an emergency. Unfortunately, Cloyd was just one of many Americans who have paid the price of the health insurance industry practice of denying ER claims.
Doctor-Patient Rights Project
According to a Doctor-Patient Rights Project (DPRP) study, Anthem has been known to give denials for cases such as Brittany Cloyd’s. Anthem and its affiliates make up the nation’s largest private health insurer. DPRP states that Anthem put forth a denial policy in order to make policyholders weary of visiting the ER for fear of receiving a bill such as Cloyd’s. This policy by Anthem has also been noted to alienate those in poor or rural areas. A spokesperson for Anthem has come out to say that their review of certain claims is meant to reduce the recent trend of an unnecessary ER visit. Anthem had not stated what constituted as an appropriate reason for one of their policyholders to visit the emergency room.
In a letter addressed to companies insured by Anthem, they stated that they did not want company employees to go to the ER for an immediate care need when they could easily visit their own primary doctor. The problem lies when cases such as Cloyd’s, who did not know her visit wasn’t an emergency but was desperately seeking help. Anthem has said that a quarter of their subscriber’s ER visits could have been treated elsewhere.
DPRP states, one in five people have recorded ER visits. This amounts to 137 million visits a year. The CDC has reported that 43 percent of all ER visits result in admissions to the hospital.
American Consumers Pay The Bill
The American College of Emergency Physicians and Medical Association have filed lawsuits against Anthem because of their policy on denying ER claims. This is essentially a violation of the Prudent Layperson Standard. These standards were set to decide, by the average person’s knowledge of medicine, whether you had sufficient reasoning to visit an emergency room. It is a ludicrous thought that a typical insured person would have to guess if their emergency is severe enough before seeking treatment.
If your claim has been denied, you may file an appeal with documentation of why your claim is valid. If the denial still stands, contact an experienced insurance claim denial attorney at The Law Offices of Sadaka Associates for a free consultation to assess your claim.