Everything You Need to Know About Insurance Denials in the Emergency Room


Being rushed to the emergency room can be a nightmare scenario for everyone involved. The stress and worry over the well-being of a loved one and costly medical services can put a lot of pressure on individuals.

Now imagine if your insurance denies coverage for this visit.

Alarmingly, it could even be deemed that your injury wasn’t really an emergency, leaving you to foot the entire bill.

Your McAllen insurance bad faith lawyers at Millin & Millin have the experience and legal know-how to accurately and successfully represent you in a court of law against bad faith insurance companies looking to shuck away responsibility to you.

Consider the following information about insurance denials of emergency room visits.

One of the Main Offenders of ER Visit Denials

Recently, Anthem, the second-largest insurance company in the country, along with its subsidiary Blue Cross and Blue Shield of Georgia, informed their clients that they would no longer be paying out for trips to the ER if they determined that the visit was not an actual emergency.

A decision based on their own standards, leaving sick patients with big worries and even bigger bills.

It would do you well to be on the lookout if you or someone you love has recently been admitted into the emergency room and is insured by this company. In many cases, patients have received large bills in surprise after their ER visits and are expected to pay the entire costs on their own.

How Anthem Did This

Anthem’s new policy on whether or not to pay an ER bill is based on a doctor’s diagnosis, not the reason the patient went to the hospital. The insurance giant defines what constitutes as an “appropriate” visit to the emergency room as anywhere “a prudent layperson, possessing an average knowledge of medicine and health” truly believes that immediate treatment is needed.

But what a “prudent layperson” and “average knowledge” is essentially left to the insurance companies imagination.

The Affordable Care Act provided a definition of a “prudent layperson” in order to protect patients from predatory insurance practices. Its original intention required that insurers based their claim payments on what an average person would consider an emergency. Now, the meaning has been twisted.

The insurer can go back after the visit and review the doctor’s diagnosis after and deem whether your trip was considered an emergency or not based on those results. For instance, an individual may visit the ER with immense chest pains only to find out that they are suffering from a severe case of heartburn.

Anthem would not consider this an actual emergency, leaving the patient to fend for themselves. Unfortunately, this may stop individuals who actually need help to shy away from visiting the ER when they actually need it.

Of course, insurance companies may claim that the goal of this policy is to decrease the costs of healthcare. Health care experts, however, state that this is more of the same bad faith insurance practices looking to squeeze out more profits from patients.

Attorneys like our McAllen insurance bad faith attorneys at Millin & Millin say that this new policy is a violation to the “prudent layperson standard” guideline, and if you have been affected, we want to help you get your voice heard.

What are the symptoms that insurance companies deem inappropriate for an ER visit?

The problem is that many “minor” symptoms can warrant a trip to the emergency room. A 2016 research paper published in the Journal of the American Medical Association (JAMA) concluded that six out of the top 10 reasons for “unnecessary ER visits” included symptoms like:

  • Back pain
  • Abdominal pain
  • Chest pain
  • Sore throats
  • Headaches

Coincidentally, these symptoms are also apart of the top 10 symptoms experienced that are correlated to real emergencies.

While this policy may have been arranged with good intentions to cut down on the costs of healthcare, it leaves patients in a precarious situation where the insurance company can deny your claim because they feel it wasn’t an emergency.

Have you or a loved one been denied insurance coverage for a trip to the emergency room? Our McAllen bad faith lawyers are ready to protect your rights.

At Millin & Millin, we fight tooth and nail for our clients, not only to give them excellent representation but to fight for the compensation they deserve. Our years of experience in battling bad faith insurance companies is to your advantage. Claim what is rightfully yours.

To set up your free legal consultation, contact us today at (956) 631-5600.