Hidden Clauses in Health Insurance Policies Severely Limit Coverage for ER Use

Imagine thinking your spouse is having a heart attack. You call an ambulance, admit them to the hospital ER, see a doctor, have multiple tests and they are put on several medications. Thankfully, it turns out to be an upper GI infection that is easily treated. You may well have run up a hospital bill that could easily exceed $10,000. Then, you get a notice from your insurance company that they will not pay the bill.

That is exactly what is happening with some insurance policies including Anthem, one of the nation’s largest insurance providers. The claim denials are showing up in several states and include private and employer based policies. Most consumers aren’t finding out about the change in policy until after they are billed for their hospitalization.

Vox reports a real life example of a woman who was taken to an ER because she thought she had appendicitis that turned out to be an ovarian cyst. She was billed $12,000 that her insurance company, Anthem, refused to pay the claim. The article also reports on how and where these denials are taking place.

When we are confronted with a medical emergency and go to the emergency room, we expect the doctors to diagnose and, hopefully, fix the problem. We also expect that our health insurance company will then pay for the emergency medical care that we received that was not only necessary, but may have saved our life.

This is not only an abdication of their responsibility, but will cost people their lives as consumers learn of these policies and choose not to go to the ER because of the financial risk. When the condition you think might be a heart attack is one, you shouldn’t have to calculate the financial risk of going to the hospital.