Prudent Layperson Standard: Your Right to Emergency Care

Prudent Layperson Standard: Your Right to Emergency Care

Get to know about the Prudent Layperson Standard, it’s truly your right to emergency care.  There are an estimated 130.0 million ER visits across the country every year. Most patients who visit an Emergency Department use their insurance plans, trusting that their insurer will honor the agreed-upon terms. However, this is not always the case, as many insurance companies try to circumvent the terms and prevent patients from fully utilizing their benefits.

To prevent this type of injustice, the federal government has provisions to protect patients from potential predatory practices from insurance companies. One of these is known as the Prudent Layperson Standard.

At Post Oak ER, the emergency room set at the heart of Houston, Texas, we’re happy to provide you with the emergency care that you need during those crucial hours.

Prudent Layperson Standard – What Does it Say?

Insurance companies have used tactics to prevent patients from receiving emergency care for decades. That is why in 1997, Congress enacted the Prudent Layperson Standard, which defines a medical emergency as follows:

The Prudent Layperson Standard defines an “emergency medical condition” as one that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious bodily functions, or serious dysfunction of any bodily organ or part.

How Does the Prudent Layperson Standard Protect You?

Initially, the law applied only to Medicare and Medicaid recipients. However, in 2010, Congress extended the policy to apply to group and individual private market health insurance plans.

The policy prevents insurance companies from engaging in unfair practices regarding emergency care, such as requiring prior approval for ER visits and denying coverage based solely on their assessment of the medical issue.

Thanks to the Prudent Layperson Standard, insurance companies are now required to provide coverage for emergency care based on the initial symptoms that drove the patient to seek medical help rather than the final diagnosis.

This is a crucial distinction because many medical conditions have overlapping symptoms and therefore require tests and a medical examination to reach an accurate diagnosis and determine if the patient needs emergency care or not.

In the past, insurance companies could deny coverage to patients who visited the ER thinking they had a life-threatening condition such as a heart attack, but it turned out to be something else. Because of this, many patients delayed seeking medical help for fear of being denied coverage and having to pay for the ER services out-of-pocket.

Texas Law Guarantees Emergency Care for All Patients

In addition to the federal provisions, the Texas Department of Insurance requires insurance companies to pay for emergency care regardless of whether the ER facility is part of their network or not. Therefore, your insurance company cannot charge you more or lower your benefits if you received care in an out-of-network ER.

Moreover, the Patient Protection and Affordable Care Act guarantees your right to emergency care without needing prior authorization.

If you think you have a medical emergency, please don’t delay seeking care, as this can compromise your life. Remember, the law protects you, and at Post Oak ER, we will always do our part to ensure you receive the full benefits of your insurance plan.

At Post Oak ER, we believe everyone should have access to quality medical emergency care near them in a comfortable and convenient location that offers advanced technology and skilled medical professionals.

Where to go in Case of an Emergency?

At Post Oak ER, our doors remain open to provide care for you and your family.