Health Insurance Question

[arizonayogaguy]

What is the name of your state? Arizona

Was in an auto accident, hit by a drunk driver. I did not go through my primary physician for care due to emergency situation, and now healthcare company will not pay for monies owed to doctor. I had to pay $5000 out of my pocket. Can I go after my health insurance company due to it being an emergency situation?

Thank you for any help.

 

[cbg]

That depends. Most plans do permit you to use non-network doctors in an emergency situation; however, if the plan does not provide for it, you can appeal but it's highly doubtful you can sue for it. If you're thinking there may be a law that says they MUST pay full amounts in an emergency, there's no Federal law to that effect but you would have to check with your state insurance commission to see if there's such a law at the state level.

What often happens is that the bills come in, in such a way that the carrier cannot tell that it was an emergency. When I was working for a national health insurance carrier, what we used to tell people in your situation was to have the hospital send a copy of the emergency room notes to the carrier, along with your request that the claim be re-evaluated given that it was an emergency.

One final note; if your plan requires that you contact your PCP within x number hours after being admitted/treated in an emergency and you did not, it's unlikely that an appeal will be fully successful.

 

[arizonayogaguy]

Thank You CBG

Thank you for the advice. I will see what I can find out. Thanks again.