Consumer Rights: Emergency Room Care

Applies to all types of health insurance plans.

You don’t need approval from your PCP or your plan before you go to the emergency room if:

Your symptoms start suddenly, and are so severe or painful that a “prudent layperson” (a thoughtful, ordinary person) with an average knowledge of medicine and health, could expect that not getting immediate medical attention would cause serious health problems or damage to your body.

For example, if you have severe chest pain and you go to the emergency room because you think you are having a heart attack, even if you are only diagnosed with serious indigestion, the plan must pay for your emergency room visit.

In the case of mental health problems: if you or someone else, again, acting as a “prudent
layperson,” thinks you would harm yourself or someone else.

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