Who gets to define “reasonably”?
In the long run, the courts. In our actual life, we here on this message board are all reasonable people, so it’s not something we need to worry about.
Bear in mind, there are many laws that refer to what a “reasonable” person would do, so it’s not like this is a new area for the courts to consider.
Ultimately, if the patient lacks the wherewithal to challenge their insurer in court, the most unreasonable staffer at the insurer will be the one whose standard of “reasonableness” is applied.
If the law is not airtight, the insurers can and will walk over their customers. They’d be foolish not to.
You seem to be assuming that none of us on this message board have to worry about how to pay our medical bills. I don’t think that’s an accurate assumption.
And the question isn’t whether we’d be reasonable about whether we had reason to think we had a medical emergency. It’s whether our insurance companies (if any) would agree – when, as has been pointed out, the company’s income is benefited by not doing so.
There is also the state department of insurance, that can intercede in cases of disputes like this. Every statement I get from the insurance company includes a paragraph on how to contact them.
The point is, in the end it’s not their decision.
Of course, I am specifically speaking of the situation in California, which is the only one I’m familiar with.
No, I’m only talking about people who have insurance. Insurance is very highly regulated, at least in California.
The two times I needed an ambulance I first called the phone number on my insurance card to see if I’d be covered.
One time I was told yes, go ahead. The other time I was told I was covered only if using my home area ambulance company. I called for them (a 40 minute wait) rather than use the hospital’s ambulance that was sitting right there. Saved me a bundle.
And, of course, depending on your medical condition, could have risked your life.
I was stable (more or less) both times. Today, as a 65 year old, I’d rather risk my life than incur crippling debt.
So would a lot of other people. But it’s a problem, and IMO a failure of the USA medical system, that people have to make that choice.
Not trying to be nasty here, but if you were stable enough to research your options and wait 40 minutes, why did you need an ambulance at all?
Transfer from the hospital where I was worked up and stabilized to a hospital 5 minutes away where they did stents. Initially I wanted to put my clothes back on and drive (that way I’d have my car with me) but it was pointed out that they’d remove my IV and I’d need it replaced, plus I was in “no condition to drive”.
Okay.
Inter- hospital transfer is a special case.
The “reasonable person” standard, that insurance is expected to cover (excepting co pays deductibles etc. …) ambulance services if a “reasonable person” would think that such was “medically necessary” isn’t applicable.
When my wife needed an inter-hospital transfer for insurance coverage we ended up waiting many hours in the ED. She was definitely stable but driving ourselves would have been “against medical advice.”
The co-pays etc. can be not cheap though.
FWIW an article about coverage.
Oh. You were already in a hospital.
That puts a drastically different context on it than the more usual context of needing an ambulance, which is that one needs to or might need to be in a hospital but instead is somewhere with few or no medical facilities.