Ms. E.K., who holds a Private Health Insurance (\u00d6SS) policy, applies to the emergency room of a contracted private hospital in the evening with complaints of sudden severe chest pain, shortness of breath, and numbness in her left arm.<\/p>\n
Ms. E.K. is intervened immediately in the emergency room; an EKG is performed, blood tests (Troponin, etc.) are conducted, and she is consulted by a cardiologist. As a result of the tests and observation, it is determined that Ms. E.K.’s condition is not a heart attack (infarction) but is caused by a severe panic attack and anxiety crisis. The patient is administered sedatives and discharged once her condition stabilizes.<\/p>\n
A few weeks later, the insurance company sends a rejection letter to Ms. E.K. for the 10,000 TL portion of the emergency room invoice paid to the hospital. The reason for rejection is: “As a result of the tests performed, the condition does not fit the definition of Life-Threatening Medical Emergency and should be evaluated within the scope of outpatient treatment coverage.”<\/b><\/p>\n
Legal Evaluation<\/b> This case reveals the most fundamental “emergency situation” interpretation difference between the insured and insurance companies.<\/p>\n
1. Definition of “Emergency”: Symptom or Diagnosis?<\/b> Insurance companies tend to define “emergency” based on the final diagnosis. That is, they argue, “If the result was a panic attack, this is not an emergency.”<\/p>\n
However, both Supreme Court decisions and the Medical Deontology Regulation (Article 13) and Medical Professional Ethics Rules (Article 32) defend the exact opposite of this approach. According to the law, an “emergency” is the reasonable belief of the patient or physician, based on the signs and symptoms at that moment, that a life-threatening danger will occur if no intervention is made.<\/b><\/p>\n
2. Responsibility of Physician and Patient<\/b><\/p>\n Ms. E.K. does not possess the medical knowledge to distinguish whether her symptoms of severe chest pain and shortness of breath are a heart attack on her own. Applying to the emergency room with these symptoms is responsible and reasonable behavior.<\/p>\n<\/li>\n When the emergency room physician sees the patient’s symptoms (findings mimicking a heart attack), they cannot turn her away saying “This is a panic attack.” They are legally and ethically obliged to perform all necessary tests to not risk the patient’s life.<\/p>\n<\/li>\n<\/ul>\n Legal Result and Solution Methods<\/b> The insurance company’s retrospective statement “it was not urgent” based on the diagnosis that emerged after the tests were done<\/i> is contrary to the law and the nature of the event. What matters is the complaints with which the patient applied to the emergency room and whether their condition at that moment required urgent intervention.<\/p>\n 1. Objection Stage:<\/b> Ms. E.K. should first submit an objection petition to the insurance company, attaching her symptoms at the time of admission to the emergency room and the hospital’s epicrisis report. In this petition, she should emphasize that her condition should be evaluated within the scope of “perceived emergency.”<\/p>\n<\/li>\n 2. Insurance Arbitration Commission:<\/b> If the insurance company rejects the objection (which is highly likely), the fastest and most effective way for Ms. E.K. is to apply to the Insurance Arbitration Commission<\/b>.<\/p>\n This application can be easily made even via e-Government.<\/p>\n<\/li>\n Commission arbitrators are insurance law experts and are familiar with Supreme Court precedents regarding the definition of “emergency.”<\/p>\n<\/li>\n The arbitrator evaluates the patient’s epicrisis report (symptoms) at the time of admission and the doctor’s obligation to perform tests in the face of these symptoms.<\/p>\n<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n Probable Result:<\/b> It is expected that the Insurance Arbitration Commission will rule that the insured’s symptoms justified the application to the emergency room and that the tests performed were mandatory to “rule out an emergency,” finding the insurance company’s rejection decision unjust and deciding on the payment of treatment costs.<\/p>\n Conclusion and Advice<\/b> The “emergency” coverage in your private health insurance policy is not valid only when a fatal diagnosis is made. Applying to the emergency room due to serious symptoms creating a suspicion of life-threatening danger is also within this scope. Not remaining silent against such rejection decisions of insurance companies and getting legal support to use quick solution methods like the Insurance Arbitration Commission will prevent loss of rights.<\/p>\n","protected":false},"excerpt":{"rendered":" Insurance refused payment saying “this is not an emergency” to a policyholder who went to the ER with severe chest pain. A case analysis on the definition of emergency, Medical Deontology Regulation, and the Insurance Arbitration Commission process.<\/p>\n","protected":false},"featured_media":895,"menu_order":0,"comment_status":"open","ping_status":"closed","template":"","project-cat":[796],"class_list":["post-896","portfolio","type-portfolio","status-publish","has-post-thumbnail","hentry","project-cat-insurance-law"],"acf":[],"_links":{"self":[{"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/portfolio\/896","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/portfolio"}],"about":[{"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/types\/portfolio"}],"replies":[{"embeddable":true,"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/comments?post=896"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/media\/895"}],"wp:attachment":[{"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/media?parent=896"}],"wp:term":[{"taxonomy":"project-cat","embeddable":true,"href":"https:\/\/sura-hukuk.com\/en\/wp-json\/wp\/v2\/project-cat?post=896"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}\n
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