How Do Health Insurance Companies Decide if an ER Visit Was a True Emergency? (International Student from a Universal Healthcare Country)

How does a health insurance company determine if an ER visit qualifies as a true emergency? Do they base their decision on the final diagnosis? For example, I understand that if someone visits the ER for flu-like symptoms, it’s typically more appropriate, cost-effective, and aligned with the level of care to seek treatment at an urgent care clinic or with a primary care provider (PCP). This approach is similar to what I’m familiar with in my country of origin.

However, in cases where it’s a genuine emergency, and an urgent care provider or PCP advises and provides a referral to go to the ER, how can an insurance company dispute that? What criteria do they use to make these decisions? Aren’t there laws in place to protect patients from being unfairly denied coverage?

How is a person supposed to know if something is a medical emergency or not? Not everyone is trained to be a doctor or capable of diagnosing themselves to determine whether something is life-threatening. For instance, sharp stomach pain accompanied by loss of bodily fluids might be the flu, but it could also indicate something far more serious.

submitted by /u/Appropriate-Trick479
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