Migliaccio & Rathod LLP is investigating whether certain employer-sponsored health plans improperly denied or reduced coverage for emergency room visits based on the patient’s final diagnosis rather than the symptoms that caused the patient to seek emergency care.
When someone experiences symptoms that reasonably appear to be an emergency—such as severe chest pain, difficulty breathing, sudden neurological symptoms, or extreme abdominal pain—the person may have no practical way to know the ultimate diagnosis before going to the emergency room.
We are investigating situations where a patient reasonably sought emergency treatment but the health plan later denied the claim, imposed greater cost-sharing, or refused to treat the visit as emergency care because testing ultimately showed that the condition was less serious than initially feared.
For example, a patient may go to the emergency room with severe chest pain because of a reasonable concern about a heart attack. If testing ultimately determines that the pain was caused by acid reflux or another non-life-threatening condition, the final diagnosis does not change the symptoms the patient was experiencing when the decision to seek emergency treatment was made.
You May Be Affected If:
- You receive health insurance through your private-sector employer, or through a spouse’s or parent’s private-sector employer;
- You went to an emergency room because you reasonably believed your symptoms required immediate medical attention;
- Your symptoms included severe chest pain, breathing difficulty, severe abdominal pain, sudden weakness, neurological symptoms, significant bleeding, or another potentially serious condition;
- Testing ultimately showed that you did not have the serious condition that was initially feared;
- Your health plan denied the emergency-room claim or paid less because of the final diagnosis;
- Your denial letter said the visit was “non-emergent,” “not an emergency,” “not medically necessary,” or used similar language;
- You were charged substantially more than expected because the visit was not processed as emergency care; or
- an appeal was denied based on what doctors ultimately diagnosed rather than the symptoms that caused you to seek care.
Why the Reason You Went to the ER Matters
Whether someone reasonably believed emergency treatment was necessary generally must be evaluated based on the circumstances and symptoms at the time the person sought care, not simply with the benefit of hindsight after doctors completed testing.
A patient should not have to correctly diagnose a heart attack, stroke, appendicitis, or other serious condition before deciding whether it is safe to seek emergency treatment.
That distinction is at the center of this investigation.
Does This Apply to Your Health Plan?
This investigation generally concerns health insurance obtained through a private-sector employer, including coverage through a spouse’s or parent’s private-sector employment.
Both self-funded employer plans and plans purchased from insurance companies may qualify. Government employee plans and certain church plans generally do not.
If you are unsure what kind of plan you have, documents such as your insurance card, Explanation of Benefits, denial letter, Summary Plan Description, and employer benefits materials may allow us to determine whether your plan qualifies.
We Are Interested in Hearing From Patients Who:
- went to the ER because of symptoms that appeared potentially serious;
- were later diagnosed with a less serious condition;
- had their emergency-room claim denied or downgraded because of that diagnosis;
- received a denial referring to “non-emergent” care or a similar reason;
- appealed by explaining the symptoms they experienced but were still denied;
- paid substantial emergency-room bills because coverage was denied; or
- have EOBs, denial letters, appeal correspondence, or hospital bills documenting what happened.
If your employer-sponsored health plan denied an emergency-room claim because your final diagnosis was not considered an emergency, we would like to hear from you. Please complete the contact form on this page, send us an email at [email protected], or call us at (202) 470-3520.