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.

(Typical wording*):

Participating Provider Services Subject to Calendar Year Deductible

Subject to all applicable definitions, exclusions, limitations, waiting periods and other provisions contained in this Policy, as well as any riders, endorsements or amendments attached hereto, and satisfaction of the Failure to Pre-Certify Treatment Deductible, if applicable, as well as satisfaction of the Calendar Year Deductible by each applicable Insured, We promise to pay to or on behalf of each Insured the Company Insurance Percentage of the remaining amount of professional fees and other applicable medical, diagnostic or treatment expenses and charges of Participating Providers that constitute Covered Expenses incurred by each Insured for the following described Inpatient and Outpatient services, which in each instance was Medically Necessary:

1. Emergency Room Services: Services Provided by a Hospital or a Participating Provider in the emergency room of the Hospital that is a Participating Provider for the following items received by an Insured on an Emergency basis:

a. Emergency room services and supplies;
b. Services for surgery in the emergency room of the Hospital, if We are notified of such surgery within seventy-two (72) hours after such surgical procedure has been performed, or as soon thereafter as reasonably possible;
c. X-ray and laboratory examinations;
d. Drugs and other medications administered prior to discharge from the emergency room;
e. Surgical dressings, casts, splints, trusses, braces and crutches received prior to discharge from the emergency room; and f. Services of a registered nurse (R.N.) in the emergency room of the Hospital.

 

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.