What Emergencies Should Health Insurance Cover?

It may shock you that your health insurance provider does not provide health insurance coverage for all emergencies. Many patients may have to pay out of pocket because they went to the ER only to find out that their emergency was considered an emergency by the insurance provider.

The lesson here is never to assume that your insurance policy will categorize your hospital visit as an emergency or provide coverage for your ER visit. Instead, you should understand what medical services your policy covers when you go to the ER and what your insurer defines as an emergency.

What Is Classified As a Medical Emergency?

According to the American College of Emergency Physicians (ACEP), the following conditions are considered a medical emergency:

  • Head/spine injury
  • Poisoning
  • Broken bone
  • Severe vomiting
  • Difficulty speaking
  • Burn
  • Difficulty breathing
  • Confusion
  • Coughing blood
  • Sudden severe pain
  • Near drowning
  • Abdominal pain
  • Uncontrolled bleeding
  • Attempted suicide
  • Dizziness/weakness

This is a brief overview of problems that you may experience that medical professionals would consider a medical emergency. There are may also be similar problems to the items on the list that would justify a visit to the emergency room. It is important to remember that when you experience a medical problem, it is always better to err on the side of caution.

Ask These Questions Before You Go to the ER

It is important to remember that your opinion of what is an emergency is irrelevant in the medical world. The only opinions that count are those of medical professionals and your insurer. While this may seem like a cold statement, knowing the difference between an emergency and a regular medical visit can save you thousands of dollars in ER expenses.

So, before you head to the ER, ask yourself these four critical questions.

1. Is the Problem Life-Threatening?

It is a judgment call you will have to make in the moment. You can easily treat a painful scrape without a doctor’s visit, but an open wound that won’t stop bleeding is different.

2. Can I Treat the Condition at Home?

You probably don’t have advanced medical equipment in your medicine cabinet. When you can’t treat the problem yourself, it’s a good sign that you should go to an emergency room for professional medical treatment.

3. Will I Injure the Person if I Move Them?

Could moving the person result in further injury? Some injuries are severe and require immediate medical attention. Examples may include severe head trauma or a neck injury. In these cases, it is best to call an ambulance instead of treating the person at home or driving to the ER.

Will the Problem Get Worse Without Professional Treatment?

Sometimes home remedies are not enough to prevent a medical problem from worsening. If symptoms show no signs of improving or if they could potentially get worse, then it’s time to get help.

What Emergency Medical Care Will My Health Plan Cover?

In most health insurance plans, you can receive as much medical care as you need as long as your health plan covers it. If you are stable but still need follow-up care, this care may not be covered if the provider is out-of-network. Be sure to follow up with an in-network provider to take advantage of your plan’s benefits.

Before you leave the hospital or doctor’s office, you’ll give the staff your insurance plan information. The provider will then send a claim to your health insurer to describe which services you received and why.

Your insurer will review the claim, send you an explanation of benefits detailing what’s been covered, and pay the health care provider. You may also receive a bill from the provider if you owe anything, such as a copay, coinsurance, or a deductible.

Contact Insurance Enterprise for Premier Health Insurance

If you have questions about health insurance and need quotes, contact Insurance Enterprise at 888-350-6605. Speak to a licensed agent and find out more about how you can get an affordable health insurance plan.