QUESTION: Will your insurance pay if you suffer a catastrophic injury or need emergency medical care?

ANSWER: It depends…

Most people think that if they have health insurance coverage, at the very least it will provide coverage if they get in a car accident or have some other catastrophic injury. However, this is often not the case. Many health insurance policies require that in-network services be used even when emergency services are required. If you are traveling or if the closest available hospital is not an in-network provider, you may end up being responsible for significant charges well in excess of what your liability would have been at in-network facility. In emergency situations, particularly if emergency surgery is required and/or is performed by out of network doctors, the out of network fees and costs can be astronomical. While it is often impossible in emergencies for you to demand or even know if you are being taken to an in-network hospital, it is important to know some of the basic policy requirements to try to protect yourself from unnecessary medical debt.

One common requirement is that you advise your insurance carrier within 24 hours or 48 hours if you have been admitted to an out of network facility. As soon as you or your family member learns that you are at an out of network hospital, request that you be transferred to an in-network facility. Often the hospital will contact your insurer as soon as possible after you are admitted. Once the hospital is aware that you are at an out of network facility and that you are requesting a transfer, it is in their best interest to attempt to negotiate an agreeable rate with your insurer. Most policies contain a provision that the insurer has the authority to agree to an acceptable rate. Further, if you are not in stable condition, it is in the best interest of the hospital and the insurance carrier to not jeopardize your health and so often a deal will be struck for the hospital to accept the in-network rate or the for the insurance carrier to pay a little more.

However, all policies differ, and HMO and PPO plans vary greatly in the types of requirements for emergency situations. It is important to read your policy and make sure that you and your family members are aware of the requirements to avoid excessive charges.

Also, don’t always take what your insurance company tells you on the phone as the final word. Often, claim representatives read from standard scripts that may not accurately reflect your rights. If you have any questions whatsoever, it is wise to put the questions in writing, and to demand written responses from your insurance company. Of course, if you still have questions, or problems, contact a lawyer with experience in this area as soon as possible. Many lawyers handle cases like these on contingency, so you may not have to come out of pocket in order to get the help you need.

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