Insurance Denied Emergency or Urgent Care: How to Appeal Immediately

Insurance Denied Emergency or Urgent Care: How to Appeal Immediately

Receiving an insurance denial for emergency room treatment is one of the most alarming insurance disputes — often arriving weeks after a frightening health crisis as a massive unexpected bill. Insurance companies regularly try to deny emergency care claims by arguing the situation "wasn't really an emergency" — even when the patient had every reason to believe it was life-threatening at the time.

This guide explains your rights, the legal standards that protect you, and exactly how to appeal an emergency denial.

The "Prudent Layperson" Standard

The prudent layperson standard is the cornerstone of emergency care coverage rights in the United States. It requires health insurers to cover emergency care based on the patient's symptoms at the time of the emergency visit — not based on the final diagnosis.

Under the prudent layperson standard: If a reasonable person with the same symptoms, under the same circumstances, would have sought emergency care — the insurer must cover the visit, regardless of what the diagnosis turned out to be.

This means:

• You went to the ER with chest pain that turned out to be a muscle strain → covered (chest pain is a symptom a reasonable person would treat as a possible heart attack)
• You went to the ER with severe headache that turned out to be a tension headache → possibly covered (severe sudden headache is a symptom a reasonable person might treat as a possible brain bleed)
• You went to the ER with a condition that could have waited → depends on the specific circumstances and symptoms

The prudent layperson standard is written into federal law (for group health plans under ERISA and for ACA plans) and into most state insurance laws.

The No Surprises Act (US, effective 2022)

The No Surprises Act provides additional emergency care protections:

• Surprise billing prohibited: Health plans cannot bill you more than in-network cost-sharing for emergency services — even if the ER or treating physicians are out-of-network
• Out-of-network emergency providers: The insurer must pay the out-of-network provider directly; you only pay your in-network cost-sharing amount
• Prior authorisation prohibited: Health plans cannot require prior authorisation for emergency services
• Balance billing protection: Out-of-network providers cannot bill you the difference between their charge and the insurer's payment (the "balance")

If your insurer or an out-of-network emergency provider has violated the No Surprises Act, you can file a complaint at NoSurprises.cms.gov or call 1-800-985-3059.

In the UK: Emergency Care Rights

In the UK, NHS emergency care (A&E) is free at point of service for all UK residents. For private health insurance disputes involving emergency care abroad or private A&E treatment:

• Pre-existing condition exclusions generally do not apply to genuine emergency care
• Most UK PMI policies cover emergency treatment (at home or abroad) regardless of whether the condition is pre-existing
• File a complaint with the FOS if your insurer denies emergency care on pre-existing condition grounds

In Australia: Emergency Care Rights

Medicare covers all emergency care in public hospitals for Australian residents. Private health insurance covers emergency treatment in private hospitals. For:

• Private hospital emergency denials → PHIO, AFCA
• Ambulance denials → Varies by state; ambulance is covered by state government in Queensland and Tasmania; in other states, private ambulance cover is needed

Common Emergency Denial Reasons and How to Fight Them

Denial: "The visit was not an emergency / not medically necessary"

Response:

1. Invoke the prudent layperson standard explicitly in your appeal
2. Document your symptoms at the time of arrival — not the final diagnosis
3. Obtain your ER intake records (triage notes, chief complaint, nurse and physician assessments at the time of arrival)
4. Include your emergency physician's letter stating that the presenting symptoms warranted emergency evaluation
5. Include a letter from your primary care physician explaining that the presenting symptoms were consistent with an emergency condition

Sample appeal language:

"This denial fails to apply the prudent layperson standard as required by [federal law / state law]. At the time I presented to the emergency department, my symptoms included [list symptoms from triage record]. A reasonable person experiencing these symptoms would have reasonably believed that their life or health was in danger, warranting emergency care. The fact that the final diagnosis was not life-threatening does not change this analysis — the coverage determination must be based on symptoms at presentation, not on the final diagnosis."

Denial: "Out-of-network provider — no emergency exception"

Response:

1. Under the No Surprises Act, insurers cannot deny emergency coverage for out-of-network providers for what constitutes an emergency
2. If you received care at the nearest available emergency facility during an emergency, you cannot be penalised for that facility being out-of-network
3. Include documentation that the emergency required treatment at that facility (you were transported by ambulance, you were in a location where no in-network ER was accessible, etc.)

Denial: "No prior authorisation obtained"

Response:

1. Federal law (and most state laws) prohibit requiring prior authorisation for emergency care
2. Cite the applicable law explicitly
3. File a complaint with your state's Department of Insurance if the insurer is requiring prior authorisation for a genuine emergency

Denial: "Service provided was not emergency care"

This arises when you went to the ER, were stabilised, and then received additional non-emergency services in the ER that the insurer is separating out and denying.

Response:

• Review the ER billing carefully — separate codes for true emergency services vs. follow-on non-emergency services
• For the emergency portion, invoke the prudent layperson standard
• For follow-on services, medical necessity arguments apply
• Request the insurer's itemised explanation of which specific services it is denying and why

Step-by-Step: Appealing an Emergency Care Denial

Step 1: Gather Your Emergency Records Immediately

Contact the ER or hospital and request:

• Triage records: Chief complaint, vital signs on arrival, initial nursing assessment
• Physician notes: Attending physician's assessment, differential diagnosis, clinical reasoning
• Test results: Lab results, ECG, imaging reports
• Discharge summary: Final diagnosis and discharge instructions

These records document what your symptoms were at the time of arrival — the key evidence for the prudent layperson argument.

Step 2: Request the Denial in Writing

If you received an oral denial or a confusing EOB, call your insurer and request the denial in writing with the specific reason and policy provision cited.

Step 3: Write Your Emergency Appeal Letter

Your appeal should:

• Invoke the prudent layperson standard by name
• Describe your symptoms at the time of presentation (using the triage records as documentation)
• Cite the applicable federal law (ERISA, ACA) or state law establishing the prudent layperson standard
• Cite the No Surprises Act if the denial involves an out-of-network ER provider
• Include the ER physician's letter supporting emergency care classification

Step 4: Request Expedited Review

Emergency care denials that affect ongoing care or involve urgent financial consequences should be appealed as expedited where possible. Insurers must respond to expedited appeals within 72 hours.

Step 5: Request External Review

After the internal appeal, request external review. For emergency care denials involving prudent layperson standard issues, external reviewers apply the statutory standard — not the insurer's internal criteria.

Step 6: File a Regulatory Complaint

File with:

• US: State Department of Insurance
• US (No Surprises Act violations): NoSurprises.cms.gov or 1-800-985-3059
• UK: FCA / FOS
• Australia: PHIO, AFCA
• Singapore: MAS, FIDREC
• Malaysia: BNM, OFS

Conclusion

Emergency care denials are among the most challengeable insurance decisions because of the powerful legal protections of the prudent layperson standard and the No Surprises Act. Don't accept a denial for emergency care based on the final diagnosis rather than your presenting symptoms. Appeal immediately, invoke the legal standards by name, and escalate to external review. Use ClaimBack at claimback.app to generate a professional appeal letter for your emergency care insurance denial.

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Related Reading:

• How to Get Your Insurance Company to Respond
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies
• Can You Sue Your Insurance Company?
• How Long Does an Insurance Appeal Take?