What is the Prudent Layperson Standard? And Why Should You Care?

Oct 22, 2019

If you or a loved woke up from a deep sleep with crippling chest pain, What’s the best course of action?

For most of us, there’s nothing quite like a medical emergency to get us out of bed. Our initial gut reaction would be to rush them to the local emergency care in Deer Park TX for immediate treatment. Right?

The answer: Yes, of course! After all, during a medical crisis, each moment is precious; and there’s little time to waste.

So, what happens when your health insurance company refuses to cover any of the bills? Unless, of course, your final diagnosis qualifies as an “emergency” under their standards.

This puts you in an unfair situation. If your diagnosis fails to qualify as an emergency, you can either:

  • Deny life-saving medical treatment, (to wave the expensive medical fee)
  • Or, receive the treatment needed to recover and risk financial debt.

In response to this injustice, Congress enacted the prudent layperson standard in 1997

What is the Prudent Layperson Standard?

The prudent layperson standard protects patients from high medical costs due to emergencies.

The great lone star state had enough of the injustice. Texas adopted this Prudent Layperson definition in 1997 through Senate Bills 385. Section 1301.155.

“The prudent layperson standard protects patients from high medical costs due to emergencies.”

Prudent Layperson Standard

Under this standard, a health plan must cover any emergency visit that results from presenting symptoms. Symptoms that a “prudent layperson” – someone who possesses an average knowledge of health and medicine—could predict that without medical attention, the situation may result in the following:

• Placing the health of an individual or pregnant woman (or unborn child) in jeopardy

• Serious impairment to bodily functions

• Extreme dysfunction of any bodily organ or part

• Severe disfigurement

This standard holds health insurance providers responsible. They must cover the cost of a patient’s visit based on their symptoms—not their final diagnosis.

Let’s say, for example; you went to an ER for shortness of breath. But you ended up having a panic attack as the final diagnosis. Here, your insurance provider legally cannot deny you coverage for your ER visit.

Before this policy, insurance providers violate the core responsibility of the medical community. Medical professionals must always place the health and well-being of patients first.

Why Does this Standard Exist?

One reason Congress passed the prudent layperson standard was because of the symptoms overlap.

treatment in an Emergency room

Someone unfamiliar with the medical industry may not know which symptoms are dangerous. They don’t know if their abdominal pain is due to a ruptured appendix (life-threatening). Or, due to an ovarian cyst (non-life-threatening).

For this reason, ER physicians need to see patients before they make a diagnosis.

Congress enacted the prudent layperson standard for a good reason. The threat of medical debt should not sway your decision to seek life-saving medical care.

Why? Because life is always more important than potential financial troubles.

At first, this Standard only applied to Medicare and Medicaid managed care plans. But, in 1999, the plans extended to all federal employee medical plans. And, in 2010, the Affordable Care Act (ACA) applied it to an individual, small-group, and employer coverage plans.

The ACA permitted that the prudent layperson standard must appear in any revisions or replacement legislation of the act.

Current State of the Prudent Layperson Standard

The truth of the matter remains: The Prudent Layperson Standard is—and continues to be—a federal law.

With the new healthcare reform, prudent layperson standard was on unsteady ground.

Bills like the American Health Care Act of 2017enable insurance providers to drop the public layperson standard. This will only further cut costs and increase their profits.

While currently an illegal trend, it hasn’t stopped some insurance companies from taking advantage.

What Can You Do to Protect Your Rights?

If you or a loved one experiences acute severe symptoms, don’t wait around. Drive to a local ER to receive an emergency medical evaluation and proper treatment.

“If you experiences acute severe symptoms, immediately head to the nearest ER for emergency medical evaluation and care.”

xray at urgent care deer park CH1ER

For those who aren’t sure which symptoms qualify as an emergency, there’s no need to worry.

Congress enacted the prudent layperson standard for a reason. Now, patients can receive the medical care and treatment they deserve without debt.

If your provider denies your claim, don’t fret! Our team will file an appeal or request an external review by a third party if necessary.

With our emergency care centers, you can rest assured that we will fight to protect your rights!

Get the Best Medical Emergency Care in Deer Park TX at CH1ER

When a medical emergency strikes, our experts are there for you. We’ll help you to file claims as per Prudent Layperson Standards. If you need any assistance, use our online forms or call at (346) 248-7081 to know more.

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What is the Prudent Layperson Standard? And Why Insurance Should be Applied for Emergency Care | Community Health 1st ER – Deer Park, TX

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