The Prudent Layperson Standard is a part of federal law that provides an important patient protection and functions as one of emergency medicine’s bedrock principles, alongside the Emergency Medical Treatment and Labor Act (EMTALA), which ensures that anyone can receive emergency care regardless of insurance status or ability to pay.
The Prudent Layperson Standard requires insurance companies to provide coverage for emergency care based on symptoms, not the final diagnosis. This is an important distinction, because 90 percent of urgent and nonurgent symptoms overlap, and in many cases doctors don’t know if your symptoms require emergency treatment without medical examination and testing. According to the Centers for Disease Control and Prevention (CDC), only about 3 percent of emergency visits are classified as "nonurgent."
A poll from the American College of Emergency Physicians (ACEP) and Morning Consult shows that nearly half (45 percent) of adults do not realize that their health insurer must cover the cost of going to the emergency department if they reasonably believe that they are having a medical emergency. This number is alarmingly high, especially when you factor in another recent poll which found that when considering going to the emergency department, nearly seven out of ten people are concerned that their insurance provider will refuse to cover them.
ACEP leads national efforts to strengthen safeguards for patients in the emergency department including recent efforts to force one of the largest insurance companies to abandon its threat to retroactively denying coverage for emergency care.
Anyone who thinks they are having a medical emergency should not hesitate to get evaluated by an emergency physician.