WOMENS-HEALTH Messages for June, 2000: Re: Insurance question-Emergency Denial

Re: Insurance question-Emergency Denial

From: AMD (anonymous@obgyn.net)
Thu, 8 Jun 2000 13:32:23 -0500 (CDT)

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Reply: Claudia Twisdale RN: "Re: Insurance question-Emergency Denial"

I suspect this is just part of the insurance company's unofficial standard procedure -- deny emergency room claims that might be the least bit questionable and deal with it when the patient complains.

I suspect an asthma attack is automatically considered to be a "chronic" ailment rather than an "acute" illness. Too many people use emergency rooms as primary care rather than having continuous care through a private physician, and so insurance companies have cracked down on what diagnostic codes will be approved for emergency room visits. If you can document that you were under a physician's care and that this particular attack was potentially life-threatening and not responding to standard home care, hopefully the insurance company will pay. However, you may have an issue if your plan requires PCP approval for ER or urgent care visits.

Also, you may want to double-check what the law is in your state for insurance companies to cover emergency room visits. I believe most state use the "reasonable and prudent layperson" standard -- if a "reasonable and prudent layperson" would consider the situation a threat to life or limb, then the insurance must cover it. For example, if all your symptoms suggest a heart attack, insurance can't deny coverage because it turned out to be indigestion.

Good Luck. Insurance can be such a pain sometimes.

Andrea

>--
>Robin
>
>At Wed, 7 Jun 2000, Estelle wrote:
>>
>>I had an asthma attack last fall. It was so severe that I had my asthma
>>specialist paged. She told me that if my readings from my peak flow
>>meter fell below 60 that I should go to the hospital but to otherwise
>>wait to see if my inhaler worked first. (I was not yet perscribed a
>>nebulizer.) When it fell below 60, my husband took me to emergency where
>>I sat on inhaled steroids and oxygen from 9:00 pm to 3:00 am when they
>>released me.
>>
>>Well, I just got a note from my insurance company, blue cross, and they
>>denied the claim citing "The service isn't payable because your contract
>>covers it only when the condition treated is either life threatening or
>>it is the result of an accidental injury caused by an outside force.
>>
>>Does this make sense? When I called BCBS they said that emergency visits
>>are only covered under "acute" condtions. What is acute? The women I
>>spoke to said that they would mail me a letter explaining my benefits.
>>She told me that I would need a letter from my doctor and the hospital
>>if I want to dispute the denial.
>>
>>Is this normal? What kind of letter from the hospital should I get?
>

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