Unforeseen, urgent or emergency medical issues can be unsettling especially if you find yourself out-of-area according to your insurance plan. Many people have questions about what their insurance provider is required to pay for in these situations. It is important to remember that a health insurance company is required to pay any non-plan health care providers in these situations providing the medical issue or emergency meets certain guidelines. Knowing these guidelines can insure that you get the best care in any situation.

If an urgent care or emergency situation arises, it is important that you know your rights so that you can get the best care possible. Urgently needed care is any illness or injury that is unforeseen or sudden. Your insurance provider is required to pay even when you are temporarily outside your service area as long as the injury or illness is unexpected when it occurs. They must pay for any medical care related to a sudden illness or injury that cannot wait until you return home.

Urgently needed care can also come in the form of an emergency. Medical emergencies are situations where you need medical care immediately due to a sudden worsening illness and injury, and the time required to reach a doctor or hospital on your plan may permanently affect your health or lead to death. Your insurance provider must pay for all procedures performed at the medical facility unless those services were unrelated to your emergency injury or illness.

When an urgent care or emergency situation arises while you are out-of-area, it is a good idea to call your insurance company to relay the situation to them; however, they cannot force you to return to an in-area doctor or facility, nor can they refuse to pay for tests and procedures if what seemed like an emergency situation turned out to not be one. They also cannot require prior authorization for emergency medical care. It is also important to know that your insurance provider cannot force a hospital to transfer you back to one of their affiliates until your current health provider considers you stable. Follow-up care must also be paid for provided that your health will be detrimentally affected if you wait until you return home. However, if the follow-up care can wait, you will be required to get these services in your area.

If an unforeseen medical emergency occurs outside of your service area, your health insurance provider is still required to cover your medical expenses. It is important to understand what your insurance company considers emergency and urgently needed care so that you can insure you are not stuck with the bill of an uncovered procedure of service.