Prudent Layperson Standard, What It Means to You


Prudent Layperson Standard, What It Means to You

Knowing your healthcare rights is vital because your health and money are at stake.

Federal and state laws allow patients to choose where to receive emergency medical care without being penalized by their insurance company.

The Prudent Layperson Standard Explained

The Prudent Layperson Standard is a federal law that provides significant patient protection.

To explain how the Prudent Layperson Standard came to be, we must first examine how insurance companies mistreated patients for years.

In the past, it was common for insurers to deny coverage or charge their members additional fees when they received care at an emergency facility outside of their network.

This practice discouraged patients in need from going to the emergency room for fear of being denied or overcharged for medical services. Consequently, many patients suffered unnecessarily, and countless individuals are now dealing with life-long disabilities due to delayed medical attention.

This unjust treatment prompted lawmakers to act, and the Prudent Layperson Standard came to be.

Prudent Layperson Standard, What It Means to You

Prudent Layperson Standard

The Prudent Layperson Standard forces insurance companies to provide coverage for emergency care based on the patient’s initial symptoms rather than the final diagnosis. This is an important distinction because nearly 90% of urgent and non-urgent symptoms overlap. And in most cases, doctors cannot reach a diagnosis and determine if the patient is having a medical emergency or not without first doing a medical examination and testing.

The law also redefined what constitutes a medical emergency:

The Prudent Layperson Standard defines an “emergency medical condition” as one that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual in serious jeopardy, serious bodily functions, or serious dysfunction of any bodily organ or part.

Prudent Layperson Standard, What It Means to You

What This Means To You

The Prudent Layperson Standard benefits all patients who feel their symptoms are severe enough to warrant a trip to the ER.

Thanks to this law, you have the following protections:

  • You do not need prior approval from your insurance company to visit the ER
  • You can choose where to receive emergency medical care
  • Your insurance company cannot charge you out-of-network fees for visiting an ER outside of your network
  • Your insurance company cannot deny or overcharge you if your diagnosis reveals a milder condition than you initially feared

Medical emergencies require prompt, decisive action from patients and doctors. If you experience any symptoms, including severe pain, which you feel can put you or a loved one in danger, please don’t hesitate to seek emergency care.

Federal and state laws protect your right as a patient to receive emergency care when needed. The Prudent Layperson Standard and Texas Insurance law prohibit your insurance company from denying or penalizing you in any way for receiving emergency care in an out-of-network emergency room.

At Rapid Care ER, we will always advocate for your right as a patient to receive medical attention. In addition, our Patient Advocate will ensure you receive the full scope of benefits your insurance plan provides.

At Rapid Care, we always go above and beyond to advocate for patients’ rights to top-rated emergency medical care. We will be here to care for you and your loved ones when you need us.