Department reminds consumers of their rights when health claims are denied

HARRISBURG, Pa., Dec. 11 /PRNewswire-USNewswire/ -- The Pennsylvania Insurance Department worked with the Office of Attorney General to take action against HealthAmerica, and its wholly-owned subsidiary HealthAssurance, for denying certain emergency room claims, Commissioner Joel Ario said today.

"No one should have to worry whether their insurance company will cover emergency care when they believe their life is at risk," said Ario. "That is why we use certain standards that require health plans to base coverage of emergency care on a patient's symptoms, not the final diagnosis. We are looking at other health insurers now to be sure they are properly applying this standard."

Pennsylvania law requires health insurers to apply a reasonable standard for medical necessity when determining the need for emergency room care.

HealthAmerica was accused of using standards that were too high and improperly denying claims. The insurer has now agreed to reprocess claims and pay bills for more than 600 consumers as part of a legal settlement.

"If you have chest pains and suspect you are having a heart attack, but the emergency room physician diagnoses indigestion, your insurance should still cover the emergency room visit," Ario said.

The department encourages consumers to read their insurance handbooks to understand their own responsibilities for coverage and care. Consumers who believe that their claim was improperly denied have certain appeal rights, depending on the type of policy they have.

"Many of us will find ourselves in need of a trip to the emergency room at some point in our lives, and these trips don't come at a small cost," Ario said. "If you believe you needed immediate emergency treatment and your insurance company will not pay the claim, then you have a right to appeal the denial."

For more information, call the department's toll-free hotline at 1-877-881-6388.

Media contact: Rosanne Placey or Melissa Fox, 717-787-3289

SOURCE Pennsylvania Department of Insurance

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