The first question you’ll be asked when you arrive in an emergency room is, “What’s wrong?”
Next comes a series of questions about your condition. The immediate focus will be on diagnosing what’s going on.
Once you’ve gone through triage and a treatment plan is underway, the questions will shift to how you intend to pay for the medical care you’re receiving. That is when the issue of insurance will come up. Can a hospital refuse treatment based on insurance status?
For emergency care, the answer is “no.” For non-emergency care and elective care, “yes.”
The level of care you receive in an ER should not depend on your ability to pay. If you believe you received substandard care because of your insurance status, it could be grounds for a medical malpractice claim.
Before you pursue a claim, you must understand the law and your rights.
Understanding Your Rights to Emergency Medical Care
According to data collected by KFF, Kentucky emergency rooms see about 514 to 539 emergency department visits per 1,000 residents. That translates to around 2.4 million total ER visits.
Every patient who enters an ER falls under the Emergency Medical Treatment and Labor Act (EMTALA). This 1986 federal law requires any hospital that participates in Medicare and has a dedicated emergency department to screen and stabilize any patient who seeks emergency care, regardless of their ability to pay.
These are the core requirements of the EMTALA:
- Medical Screening Examination (MSE): Hospitals must provide an appropriate exam by qualified medical personnel to determine if an emergency medical condition (EMC) exists. The hospital staff cannot delay that screening to ask a patient about payment or insurance.
- Stabilizing Treatment: If an EMC or active labor is present, the hospital must provide treatment to stabilize the patient.
- Appropriate Transfers: If the hospital lacks the specialized capability to treat the patient, it must arrange an orderly transfer to a hospital that can treat the patient, and a receiving hospital with the proper capacity cannot refuse the transfer.
EMTALA is an unfunded mandate. That means the law requires the hospital to provide care, but it will not be directly reimbursed for that care. Medicare or Medicaid can offset some of those costs.
If a hospital refuses care they can face substantial fines, be terminated by Medicare, and be subject to a lawsuit.
When Hospitals Can Legally Turn Patients Away
EMTALA only applies to emergencies. If you are seeking routine care, check-ups, or elective procedures such as a scheduled hip replacement, the hospital can verify your insurance before admitting you. They can also require payment upfront or refuse to schedule the service altogether. In that scenario, you would have no legal recourse.
A hospital is not required to provide a specific treatment or procedure if it does not offer it or is not equipped to handle it. For example, some local Kentucky facilities may not have the capabilities to treat neurological or pediatric trauma.
In that situation, the hospital is supposed to stabilize the patient and provide transportation to a facility that can provide the proper care. Additionally, hospitals may legally refuse non-emergency care if a patient is aggressive, violent, exhibits dangerous behavior, or is acting out due to non-illness-related issues.
Under Kentucky regulations, however, a patient has the right to refuse medical or psychiatric treatment unless there is a documented emergency or a court order.
Identifying Medical Malpractice in Treatment Denials
If a denial of treatment has harmed you, you may be able to file a civil complaint against the hospital or medical staff. A denial isn’t just about being turned away at the hospital. It can also include denying you a standard of care through a regular doctor’s visit.
It would only be an actionable cause in the following scenario:
· Your Doctor Ignores Obvious Symptoms
If your doctor refuses to order basic or necessary diagnostic tests despite textbook symptoms of a life-threatening or progressive condition, it could be a sign of neglect.
· Your Doctor Fails to Refer You to a Specialist
You might present with a condition to your primary care physician who fails to refer you to a specialist. This can lead to further health complications and a potential legal claim.
· Your Doctor Disregards Your Medical History
Your medical history provides valuable information about past illnesses, allergies, and other potential complications. If your doctor denies or alters your care plan without accounting for documented details in your history, it could lead to complications.
Getting Legal Advice for Refusal of Care
If you feel like you’ve been denied medical care, you need to consider your legal options for a remedy. This applies whether you were turned away in an emergency room because you lacked insurance or your doctor denied care. Those legal options can include filing a medical malpractice claim that can lead to a civil lawsuit.
That’s when you need to speak to McCoy & Hiestand. Our legal teams have helped many Lexington residents pursue viable medical malpractice claims. These require extensive investigations.
They also require a Certificate of Merit.
That involves finding an independent medical professional who can review your records and attest that your claim has merit. We can lock down the right medical practitioner to provide the certificate. We’ll also take over all communication with the insurance carrier in hopes of a fast resolution.
You can get your questions answered during a free consultation with our legal team.
Call to schedule the talk, and let’s find out what needs to happen next.
