r/HealthInsurance • u/WitnessNo393 • Mar 21 '25
Claims/Providers My sons $7,000 ER visit claim denied due to "Willful Misconduct"??
I actually can't believe this is even a thing but here it is on the EOB right in front of me.
In a nutshell: my 20 year old son is on my insurance. While camping with friends some substances were ingested and he began to have feelings of impending doom and that his life was in danger to the point that he eventually asked one of his friends to drive him to the ER over an hour away. He was treated, felt somewhat better and left.
Now we've received an EOB (pic below) saying "Services denied due to Willful Misconduct".
I would love any suggestions and advice on how to get my health insurance to pay this claim. Thank you in advance!
EOB: https://imgur.com/a/6Lk7KKA
Edit: (Location is California)
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u/ElleGee5152 Mar 21 '25
It sounds like this insurance plan excludes services for things like overdose/drug use. I work in ER billing on the provider side and don't see this denial a lot, but it does happen. There isn't much you're going to be able to do with the insurance if there is a coverage exclusion. They will want to see the medical records with an appeal. I would have him apply for financial assistance immediately. If he isn't approved, you do have room to negotiate by asking for a self pay discount since this isn't covered by the insurance. Self pay discounts usually run from 30-60% of the charges, depending on the facility's financial policies.
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u/ArdenJaguar Mar 21 '25
It’s similar to how many auto insurance companies won’t cover an accident if you’re under the influence. Same line of thinking.
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u/BrandonBollingers Mar 21 '25
Yes but usually a dui has some legal basis. A "dui" is a codified crime and the state has to prove it beyond a reasonable doubt.
I have a lot of questions about what constitutes "wilful" and "misconduct". How can they prove that is actions are misconduct? How can they prove it was willful?
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u/Straight-Note-8935 Mar 21 '25
Some insurance policies will exclude coverage for injuries from "extreme sports" like surfing, rock climbing, bungee jumping, scuba diving, and motorcycles.
https://alea.care/health-insurance/how-exclusions-impact-your-health-insurance38
u/WitnessNo393 Mar 21 '25
How do I find out if there is an exclusion for overdose/drug use? Would I request a copy of the policy from my insurance?
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u/SpecialKnits4855 Mar 21 '25
Yes (or something called a Summary Plan Description, if it's an employer sponsored plan).
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u/Derwin0 Mar 21 '25
The EOB pretty much confirms there’s an exclusion.
But you can probably look it up on your providers website.
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u/throwawayeverynight Mar 21 '25
Call your insurance , they should be able to go over the policy with you and send you documentation to what is excluded. Have your son apply for financial assistance from the hospital just keep in mind that he may still have to request discount all the providers he saw ER doctor.
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u/DomesticPlantLover Mar 21 '25
Since they list that as a reason, you can be almost positive it's in the policy. You could ask for the specific wording of the policy, but if they cite it as the reason, it's in the policy. Ask for the section/paragraph citations. It's likely online--they may be able to send you a link to it.
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u/SparkySkyStar Mar 21 '25
I mean, I have had an EOB that denied a claim for the reason "non-covered procedure" when it was not only covered but pre-approved, and the same EOB paid for the other parts of the procedure that had different billing codes but had been approved under the same pre-authorization!
It's likely in the policy, but EOBs can absolutely have errors.
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u/yobabymamadrama Mar 21 '25
The emergency room looks like it's billing to the insurance as non-urgent. Almost all policies exclude use of the emergency room for non-urgent issues. So your fight might be with the emergency room.
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u/bigpurpleharness Mar 21 '25
I mean being paranoid after taking something that's known to make you paranoid most likely isn't going to be changed.
People used to complain to me all the time when their ambulance bill wasn't covered after they called 911 for a common cold.
No I'm not putting you're having a cardiac event just because webmd told you shortness of breath is a sign of a heart attack when we both know you have a cold and you're "shortness of breath" is congestion.
I only say this because in the 4 states I've been licensed in, the ERs were the same way. Sure, plenty of overtriaging CYA happened but for things like this? Were not committing federal insurance fraud because someone wants to go around their insurance.
Either way, fuck health insurance corpos and universal health care for all would fix this.
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u/Woodman629 Mar 21 '25
You should have access already to very detailed information about your plan. It is required by law. It was probably mailed to you in a paper format and you most likely have access to it online.
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u/Primary-Platypus-696 Mar 21 '25
How does one become aware of exclusions like this in their policy? For me, my employer handled those agreements with insurance providers. What do I ask to see to understand any exclusions?
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u/manderrx Certified Professional Biller Mar 21 '25
Apparently my work has ruined me, I cringed at 30-60% and then remembered we’re way over the average (50-98%, but everyone gets 50% for turning in the paper regardless of insurance status).
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u/Big-Al2020 Mar 21 '25
Why are self pay discounts a thing?
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u/Sea_Egg1137 Mar 21 '25
Because providers are willing to offer those patients without insurance, a rate that is comparable to the one they offer Medicare, Medicaid, etc.
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u/BusyBeinBorn Mar 21 '25
Lol, the discounts are for the insurance companies. My only hospital stay resulted in a bill of $40,000, but insurance paid $9,000 and I paid my annual OOP max of $1,500.
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u/Jujulabee Mar 21 '25
This appears to be an employer self funded plan so they are subject to ERISA Federal law and not state law.
Exclusion for care needed for illegal drugs is permit under Federal law.
I think it might be an interesting case if the drug is not illegal in the state it is ingested. For example, in California recreational use of marijuana is legal but it is illegal under Federal law even in California which is why typically credit cards often can’t be used in the pot shops.
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u/WitnessNo393 Mar 21 '25
Thank you for your help! It is an employer self funded plan.
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u/Jujulabee Mar 21 '25
Sometimes employer funded plans have more flexibility because they are the ones determining plan benefits and so can change benefits to eliminate a specific exclusion.
If it was a weed and it occurred in California where weed is legal I would at least contact HR and see if it is covered since it is a legal recreational drug and theoretically might be included since it isn’t willful misconduct.
It woukd Be odd to have such a broad interpretation of misconduct since that could include a kid being reckless on a bike or other normal childhood accidents since they are willfully and “misconduct”
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u/Derwin0 Mar 21 '25 edited Mar 21 '25
Federal law, as well as those in 34 States, allows for an exclusion for the treatment of injuries caused by illegal drug use.
Just be glad he’s still alive to learn from this expensive lesson.
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u/WitnessNo393 Mar 21 '25
Appreciate the response. Thank you!
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u/Evamione Mar 21 '25
Also, because he is over 18, this is his bill and not yours. He can apply for financial aid based on his income. If he still can’t pay the bill, you can file for bankruptcy.
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u/546833726D616C Mar 21 '25
Sounds like he needs to allocate a percentage of his illegal drug budget to an HSA. Think of the tax savings.
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Mar 21 '25
[deleted]
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u/Cute-Contribution592 Mar 21 '25
This is the way. I heard tho that they are starting to take people to court for as little as 2k and get judgments where before I heard it would have to be over 10-15k
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Mar 21 '25
Which 34 states and/or where can you find out if your state is one of them? I’m interested to learn more. That seems like a crazy law, especially because people get drugged without their consent unfortunately often. And it’s reasonable to assume that should be covered for an er visit if a person was fearful they were dying. But how do you prove one way or another to make the distinction? Like, do they allow insurance to not cover any emergency if an illegal drug is involved? Are these decisions based on reporting from the nurses/doctors? Are they the words of the person while still intoxicated or their recounting of what happened after?
Should a party goer only ever say they think they were poisoned if they had a medical emergency in one of those states after doing drugs?
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u/hhhnnnnnggggggg Mar 21 '25
This will just lead people to be untruthful about what they ingested to doctors
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Mar 21 '25
This is one concern that crossed my mind. As well as it would reduce the number of addicts and at risk people looking to get help generally.
I have no idea how those laws are written, which is why I was asking. It seems like there could be a lot of potential gray areas for people to fall through the cracks. I want to know where to find out if my state is like that. As in, what’s the law called so I can read more.
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Mar 21 '25
We know what you took.
-the paramedic.
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u/hiraeth_stars Mar 21 '25
I had a paramedic tell me once it was 'refreshing' to have someone be open and honest about what they took. Do people really lie about it that much?
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Mar 21 '25
You can narcan someone back to life in a room littered with baggies and syringes and they’ll deny it.
It’s fear of the police. And shame. Ironically the police have really changed, they’re often the most compassionate people in the room. Frankly it’s us EMS guys that have compassion fatigue.
People lie. But most drugs have clear physiological indicators and psychosocial clues. We can usually figure it out.
Some folks are shockingly honest.
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u/hiraeth_stars Mar 21 '25
I was always raised that the one person you don't lie to is a doctor because it's the stupidest thing to lie about. They already know you're high or drunk, or that you never exercise and eat like crap, why bother making things difficult by lying?
I just figured, at that point, lying would only irritate the emt guys and make things more complicated so I was just honest about it. They knew I took shit, why drag things out?
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u/Alive_Restaurant7936 Mar 21 '25
Was an ER nurse for many, many years. People lie all the time. They will lie straight to your face. Swear they "didn't take anything." Have a tox screen that was positive? "Someone must have slipped it in my water" or "someone must have touched me with meth on their hands." When someone was honest, it was refreshing.
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u/hiraeth_stars Mar 21 '25
That's just crazy to me. I guess I'm glad my parents raised me to be honest about that kind of stuff.
My ER nurses always raise their eyebrows when I just admit to smoking weed though. I figured that would be the least surprising thing for people to admit to!
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u/Alive_Restaurant7936 Mar 21 '25
I am a provider now so no longer in the ER. I honestly have 0 cares if my patients tell me they smoke weed. I can tell that most expect to say something negative but if it helps with your pain, then so be it.
When I was still an ER nurse, I'd rather deal with someone who smoked weed than a drunk any day of the week.
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u/hiraeth_stars Mar 21 '25
Ugh yeah, drinks are no fun for anyone to deal with but I bet it's especially bad working in medicine with them.
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u/Sea-Swimming7540 Mar 21 '25
They will jut run blood work and find out. They aren’t stupid 🤷♂️. Anyone who comes in acting crazy probably gets drug tested to be honest
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u/bakercob232 Mar 21 '25
i see this mentioned alot, would anyone really rather be dead than have their credit score take a hit?
I dont know if its working in the medical field or having providers around most of my life but id rather have my wages garnished because that means im alive to be working and earn a wage than be on a slab in the morgue. Be honest with your doctors so they can do their jobs, ER docs just wanna make it through their shift with as few complications and negative health outcomes as possible-please dont explicitly work against them
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Mar 21 '25
Would a person rather be dead than live in crippling debt for the rest of their lives? Not to be mean, but your statement seems pretty ignorant of just how awful poverty and some circumstances can be. Your statement also makes the assumption that the person will get out of the hospital and still be able to work. It’s assuming the debt isn’t being piled onto reduced work capacity and loss of wages or general loss of the persons job just because they were out of work being in the hospital. Loss of a persons home, inability to pay bills…
That’s a more realistic look at what some people will face after a major hospitalization, especially if they are left with lasting injuries. It’s very easy to understand why people gamble- even if the person is alive after all that, they still have an outcome that ruins their life.
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Mar 21 '25 edited Mar 21 '25
I’m glad you still have your mom, obviously.
But as a person who is looking at eventually dying of a debilitating degenerative condition, who’s also going to have to watch her father likely die of a similar condition- there is absolutely a reason people draw a line in the sand at some point. No, it’s not ideal, it’s incredibly sad. Our system shouldn’t make people choose between their life and their quality of life, but that’s the case for a lot of people. You have emotions wrapped up in this because you almost lost your parent. I get it, I’m fucking terrified of losing mine, but when he eventually chooses to stop seeking treatment it’s not my place to stop him. He’s told me that time will come and it’s as much for his own dignity as it is for his concern with finances. We watched my grandpa die slowly chocking on the water in his own lungs, that ain’t the way to go. It’s probably one of the worst ways possible frankly. At a certain point I would much rather die knowing that would be it vs knowing that after that point it will all be down hill suffering. I don’t want that for my family or for myself. I’m certainly not going to cost my family their house so that I can be around for a questionable amount more time while perpetually needing care that is unable to be provided. That’s not good for me or them. Grief sucks but it’s inevitable it will happen some point or another. Maybe it’s the idea of getting comfortable with the thought of death- but there are much worse things in life that are possible than death.
That said, I want to be clear, the system we have is appalling and no one should ever have to make the choice between life and the negative outcome of what their life would look like after choosing to get care. No one should ever have to question going to the ER for an emergency. It’s disgusting that we don’t just have universal healthcare at this point. I’m just defending, there are damn good reasons why people make the choice to risk dying vs to get care. It would be great if the system alleviated those issues and maybe people would be less likely to consider external things aside from their ability to bear physical experience of recovering from certain ailments.
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u/bakercob232 Mar 21 '25
Universal healthcare would not solve these issues otherwise we would have a standardized system across the globe-every country with a socialized health program is structured differently and all have benefits and faults. It is not an emotional stance to say that in general people want to live, even those that are sick. While no one can force you to go through a treatment or follow medical advice, you dont get to say anyone who chooses to take on debt to survive is privileged. You and your family are making the choices that feel right for you because fighting is tiring, if that wasnt part of it the "dignity" wouldnt be a factor being considered.
Yes medical care is extremely costly, but you cannot discredit the changes in policy, advances in treatment and options for insurance that have occurred in the last 20 years.
If I am privileged for stating I would rather have to pay for an ultrasound or have debt from that than die from a PE so be it.
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Mar 21 '25 edited Mar 21 '25
I didn’t say your first comment was privileged, I said it was ignorant of the circumstances that people find themselves in after a major hospital or ER visit. But yeah, this addition is pretty damn privileged on top of that. The reality is that in this system, if you can’t pay for an ultrasound, then you don’t get one at all. So that person who has no way to pay, no way to put it on credit- in this system that person likely dies because they can’t even access treatment to find out what’s wrong. Forget getting treatment to the thing that’s killing them, they can’t even get a diagnosis . Likewise, if that person is in the ER for a medical crisis because they couldn’t afford the ultrasound, they basically then get stabilized and then sent on their way. Only to end up back in the position of not being able to afford follow up care.
You absolutely can discredit the changes and “advancements” in policy and insurance options- the system is still fucking broken. People are still dying and having their lives ruined while corporations make billions and ceos make 352 times what their employees make (united healthcare for example). There is nothing defendable about the system. It’s still harming people at a staggering scale.
The fact that you think medical advancements are due to the extreme cost of care is naive. Our taxes already pay for a significant portion of medical research that’s done via grants and other things. There are absolutely ways to fund medical research without allowing corporations to pray on people who need care to survive. In fact as a personal anecdote, the most recent helpful research for my health issues came from funding in countries with universal healthcare- tax funded research that was focused on making people better and not on providing a product that a company can market and profit off of. There is a lot of critical research done in that isn’t based on creating new products that will increase profits for drug companies. The drug companies here don’t even have new clinical trials going because it won’t make them money with new patents. Once again, another example of our flawed system.
If you want to keep making billionaires and centi millionaires richer via paying your excessive healthcare bills then you can keep that privilege. Don’t fool yourself thinking it’s helpful or making access to care better though.
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u/bakercob232 Mar 21 '25
my mom has been fully disabled and unable to work since I was 3 years old, she's been septic from a stomach perf, had grand mal seizures on the couch in our living room, randomly collapsed and not come back without EMS intervention. We are all much happier that she is alive than whatever debt was incurred by accomplishing that. I have seen my father in tears on the phone with 9-1-1 screaming that he thinks his wife is dying more times than anyone should-at no point did he think about whatever bill was coming in the mail.
no part of that is a "privilege". if you think it is I'd gladly trade places with you any day of the week.
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u/Pale-Application2607 Mar 21 '25
My understanding is medical debt no longer affects credit scores.
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u/bakercob232 Mar 21 '25
i should have clarified ty for bringing it to my attention genuinely.
This is why its best to make payments on the bills when theyre still under the hospital, before getting sent to collections which is what will happen to everyone that says to just ignore them
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u/bakercob232 Mar 21 '25
a SAFE exam or any services provided while filing a criminal complaint are not billed in the same sense as someone recreationally consuming a substance and then seeking treatment for a nonemergent health status. Yes kids do dumb things and should be allowed to make mistakes, but they are responsible for the fees associated with those mistakes.
Someone who injures themselves or others due to their misuse of substances generally does not evoke the same coverage that someone who is actively seeking treatment for the substance abuse issue; and even then a lot of plans dont have coverage for in patient rehab or treatment facilities.
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Mar 21 '25
Is what you’re saying, that the policy to not cover an ER visit for a possible OD, only in the event of the police or law enforcement getting involved?
Because what wasn’t covered here seems to be the kid showing up to the ER with his friends saying he possibly ODd and felt like he was dying.
What if this was a kid coming in after a night at the bars and their drink was spiked- their friends are worried about their condition and say they think it was drugs put in their drink- where is the differentiating factor here? The way it’s reported to nurses?
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u/bakercob232 Mar 21 '25
no where in the post does OP say her son had any life threatening symptoms when he was evaluated. An ER visit for a drug induced panic attack is not the same circumstances, coding, or treatment for someone who is unconscious and aspirating, someone whos drink is spiked and they are having decreased respiration and has no way of knowing what they ingested or someone with no pulse who is revived with narcan.
"I took too many shrooms/tabs/hits from a joint, im in the woods and its dark and im scared" is not the same as someone who is actually at risk for losing their life based on decreased bodily function.
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u/LibraryMegan Mar 21 '25
But people go to the emergency room all the time thinking they’re dying only to find out it was a panic attack. Insurance still covers them, even though they were never actually in any danger.
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u/bakercob232 Mar 21 '25
an GAD induced panic attack is not the same as one brought on by using what is considered to be an illicit substance
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u/bg8305496 Mar 21 '25
If you have a self funded employer-sponsored policy, you will need to look at your summary plan description (this is your coverage contract) and review the exclusions section. If they’re denying it saying that it’s related to “willful misconduct,” then there should be an exclusion that defines willful misconduct.
If you have any other type of insurance, you will need to look at your policy and review for exclusions. If the policy is subject to state law, California may limit what is excludable.
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u/WitnessNo393 Mar 21 '25
Appreciate the help! It is a self funded employer-sponsored policy. I'll take a look at the summary plan description.
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u/bg8305496 Mar 21 '25
If there’s no exclusion that would apply, I’d appeal the denial arguing that the SPD mandates coverage.
I’d read through all of the exclusions to make sure that none of them apply. Good luck!
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u/Enough_Island4615 Mar 21 '25 edited Mar 21 '25
It's worth appealing. 'Willful Misconduct' requires that he ingested a substance or substances where he KNEW that these were the potential consequences. Or, that he KNEW his health and life were not in danger but chose to go to the ER anyways. It is definitely worth a try. Less than 0.5% of people appeal denials and more than 50% of these appeals result in a reverse of the denial. Also, look at your policy (or feed it to AI) and see if it specifically mentions these substances.
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u/Physical_Ad5135 Mar 21 '25
It is likely a legit exclusion. Ask for self pay discount and make sure your son pays for the costs. He can setup a payment plan with the hospital and remember how stupid and unnecessary this was every time he makes a payment.
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u/BogBabe Mar 21 '25
If there's a drug and alcohol exclusion in your insurance coverage, then that would likely be the basis for denial. Perhaps it's an important lesson for your adult son to learn: when he engages in illegal, risky activities, he should expect to pay for the resulting damages himself.
"Substances were ingested" is another way to say "he took illegal drugs" without placing the decision to do so squarely on his shoulders. But he made that choice. Now he gets to pay the piper.
You should read your insurance policy coverage explanations thoroughly. It can't hurt to appeal the decision.
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u/yll33 Mar 21 '25
"Substances were ingested" is another way to say "he took illegal drugs"
classic use of passive voice instead of active to deflect blame
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u/Leverkaas2516 Mar 21 '25
he should expect to pay for the resulting damages himself.
On the other hand, if it's true that "he was treated, felt somewhat better and left", how did that get to $7000? Did the whole ER team have to fly in a helicopter to gather the pistils of some rare plant and devote hours preparing some tincture?
If the cost was for actual services rendered, the policy exclusions wouldn't be that big a deal.
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u/Woodman629 Mar 21 '25
Going into an ED room for any kind of treatment is about $4500,-$5000 alone. Add doctors and labs to that and there you go.
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u/Mandinga63 Mar 21 '25
Cost my daughter $800 for ER visit after a dental extraction and the dentist didn’t answer the emergency number. Her jaw was swollen way out on a weekend so she had to go. Come Monday, I called his office and said if you have an emergency number, you need to answer it. You will be paying her ER visit. Not only did they pay the $800, they also wiped away the whole $1,600 for her extraction and implant.
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u/Woodman629 Mar 21 '25
Level 1 through Level 5 --- how much care is needed and how life threatening. Different level, different cost.
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u/BogBabe Mar 21 '25
I looked up that code for the biggest charge — 99285. It’s for the highest-level and most expensive ER visit. It includes, among other things, “toxic ingestion.”
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u/tacsml Mar 21 '25
Sounds like a lesson for a young man to learn. You are not responsible for this bill.
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u/random_chaos_coming Mar 21 '25
What lesson? To not ask for help when you feel suicidal? Many suicides accompany drug use as folks self medicate, even if that’s not what happened here. This is insurance bullshit considering suicide is a huge risk for young men. While I understand pragmatism, this is just wrong.
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u/anonymouseinahouse Mar 21 '25
Where does the OP mention those were the feelings of impending doom? Cause when I did drugs, my impending doom was not thinking about offing myself or others, it was "this drug is going to k ill me"
Surprise, it was only weed
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u/laurazhobson Moderator Mar 21 '25 edited Mar 21 '25
I smoked weed for MANY years as I started in the 1960's. I have also dabbled other psycheelics such as LSD, hash but not some of the newer drugs.
I stopped taking weed because I began to get paranoid feelings just from weed so it is possible with weed especially with newer strains of weed that are cultivated to be extremely potent.
When I first starting smoking weed it was fairly mild. I remember the first time I had what was then called "Thai stick" which was literally buds on a small twig and it in no way resembled the high I was used to on the older stuff. But I was fine with it and it was only much later that weed was no longer "fun" and so I stopped.
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u/tacsml Mar 21 '25
He did illegal drugs. This is a consequence of that 🤷♀️
It sucks but...it is what it is.
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u/laurazhobson Moderator Mar 21 '25
Weed is legal in California even for recreational use.
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u/tacsml Mar 21 '25
Well, I don't know what drug was taken. I don't think OP specified? But, I am assuming it was illegal.
Regardless, while weed is legal at the state level, it is illegal at the federal level.
Like, I live in a state where it is legal but many jobs prohibit its use by employees because they have to comply with federal laws.
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u/One-Rabbit4680 Mar 21 '25
Why do you say they aren't responsible? is there a catch I'm missing. Share it so if there's a special law or something that protects the person we can learn from it.
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u/Derwin0 Mar 21 '25
The son is an adult, so he’s the one responsible for the bill, not his parent (OP).
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u/quigonskeptic Mar 21 '25
I thought the person holding the insurance is responsible for the bill? Is what you are saying true in all the states, or is it state specific!
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u/Comntnmama Mar 21 '25
Nope. Just because you are the policy holder does Not make you the guarantor. If a person is over 18 they are responsible for the bill. True for all states.
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u/quigonskeptic Mar 21 '25
This is good to know. I've always been the guarantor and didn't think through how that would change based on their age.
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u/SlowMolassas1 Mar 21 '25
Each individual (adult) is responsible for their own medical bills. The insurance just determines how much they owe on that bill, but does not change who is responsible.
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u/quigonskeptic Mar 21 '25
This is good to know. My kids pay their medical bills, but I thought that if they didn't, I would be on the hook.
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u/Janknitz Mar 21 '25 edited Mar 21 '25
How horrible to have this hanging over your head after all that worry for your son!
I once helped a family whose son deliberately made himself undead, but he did not die right away--he was in ICU for a few weeks before he passed. Insurance denied the entire claim because they said that the act was an exclusion in their plan.
We requested a copy of the Evidence of Coverage (EOC, not to be confused with an EOB). The EOC is the actual contract between you and your insurer, but you may have never seen it unless you know how to ask for it. Nowadays many are posted online, or you can request a written copy from the insurer by mail, and most states have laws requiring the insurer to get it to you within 7 - 10 days of a written request. Make sure you get the Evidence of Coverage, NOT a plan summary.
Interestingly, the EOC did NOT have any exclusion for attempting to undead oneself. When I called them to point that out, they said "well, it's usually excluded in our policies." But it wasn't excluded in THAT policy. "Usually" is not good enough. So in the end they paid up.
My first bit of advice is DO NOT ASSUME THEY ARE TELLING YOU THE TRUTH ABOUT A WILLFUL MISCONDUCT EXCLUSION. Get a copy of the EOC--make sure it's the one for the exact policy under which your son was covered, and see if you can find "willful misconduct" as an exclusion. If you cannot find it in the EOC, all them and ask them to show you where in the EOC it is excluded (if it's now stated exactly that way and they are trying to shoehorn the definition of something else into "willful misconduct" then seek legal help). If it's not in there and they admit it, they must pay up.
If it's in there, though, your case is difficult. Talk to a lawyer who does insurance law to see if you have any recourse. You should also find out if you have any financial liability since your son is an adult--he is essentially "Judgement proof" at this age. You may not have financial responsibility, even if he was on your plan.
If all else fails and you are financially responsible, negotiate with the hospital and consider something like a Go Fund Me to get help from friends and family.
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Mar 21 '25
Go over your insurance policy documents with a fine-tooth comb. There's a good change it won't be covered, but look really closely to see if there's anything you're missing. Maybe it's not a blanket exclusion for everything related to illicit drugs, for instance. Or maybe it is.
If it really can't be covered, contact the hospital and see what options there are. Maybe they'll reduce the bill and/or give you the uninsured rate.
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u/Straight-Note-8935 Mar 21 '25
Insurance is so interesting! From a 2023 study that includes a map of state laws:
"We found that 18 states still have Alcohol Exclusion Laws, down from 37 in 2004. Meanwhile, the number of states that have explicitly banned AELs and prohibited insurers from applying Alcohol Exclusions (AEs) to their policies has increased from 3 to 15 in the same period. The remaining 17 states have no clear laws on AEs. We also noted that five states that repealed their AELs did not adopt any specific prohibition on AEs, and four states limited their prohibition to policies that cover hospital, medical, or surgical expenses.
https://pmc.ncbi.nlm.nih.gov/articles/PMC10699208/#:\~:text=Results%3A,15%20in%20the%20same%20period.
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u/UnitedIntroverts Mar 21 '25
The Plan Document, which is the entire book of rules for you plan is where you would find the exact exclusion as well as what is covered.
6
u/visitor987 Mar 21 '25
You and your son(since he is an adult) must both sign and file a WRITTEN APPEAL within a few days!! I believe your appeal rights are listed on the EOB but I could NOT make big enough to read . Send the appeal by email(if known) and also certfied US mail (you may have call for address). Certfied mail has the post office certfied your insurance received the appeal with the time limit
Use of of illegal drugs by an adult is often not covered but an appeal is worth a try. It a good thing your son went to the ER otherwise he might be dead.
Your son is an adult so he owes the claim not you. Any bills received in your name should be returned stating you received no treatment and your son's name is an adult. If you are sued in a court you must show up or you lose by default Your defense is your son is an adult and you received no treatment.
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u/LowParticular8153 Mar 21 '25
If a claim is due to illegal activity a denial may happen contingent on the policy.
Ask provider how billed. The medical records probably mention law enforcement involved?
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u/WitnessNo393 Mar 21 '25
I'll check it out and see. I don't believe law enforcement was involved. Appreciate the help!
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u/Independent-Stand Mar 21 '25
He's 20 and would have signed for himself. He used the insurance, but the bill would still fall on him. Applying for financial assistance sounds good, and he might get it. If he doesn't have the $7k and they won't write it down, then I suppose they can pound sand trying to get it from him.
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u/velvedire Mar 21 '25 edited Jun 08 '25
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This post was mass deleted and anonymized with Redact
8
u/Reason_Training Mar 21 '25
Check with your insurance. If the diagnosis was altered mental health due to illegal substance it can sometimes be covered under the mental health coverage. They may be denying it due to an exclusion in the policy but also because there may be a carve out plan.
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u/MinimumCarrot9 Mar 21 '25
OP, in the very likely scenario that your insurance does not budge on the decision to not pay, call hospital billing directly and negotiate the bill down as much as you can.
Also, please look into substance addiction counseling for your child.
Wishing you all the best.
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u/OkAgent209 Mar 21 '25
I had a policy in graduate school that excluded any injuries playing intramural sports, including injuries going to and from games… 🙄
4
u/KcjAries78 Mar 21 '25
I think the real problem is that an ER visit is $7,000 without insurance coverage.
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u/LovYouLongTime Mar 21 '25
Yup, drugs ain’t covered.
Sorry, but not sorry. Time to teach Timmy about real life and consequences.
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u/BrandonBollingers Mar 21 '25
I really don't know but I would ask what they define as Willful Misconduct and what evidence was used to determine that the conduct was both "wilful" and considered "misconduct".
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u/mtaspenco Mar 21 '25
Substances were injested? Talk about not taking responsibility.
Your son messed up. He’s over 18. Now let him figure out how to pay this bill.
Time to cut the apron strings.
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u/Intelligent_Belt5741 Mar 21 '25
EOB states it’s not covered but look it up in your Certificate of Coverage, Summary plan description or plan documents.
3
u/Woodman629 Mar 21 '25
A denial won't be successful. It is a policy exclusion. There is nothing to appeal.
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u/Fatkidinkmart Mar 21 '25
I’m gonna be an asshole for this but what the actual fuck? Dude went to do drugs with his homies, guessing some shrooms or something along those lines and then panicked and went to the er… yeah, your kid took time away from actual emergencies and you should h e to pay every penny of that.
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u/Word_Underscore Mar 21 '25
I punched a mirror about 20 years ago and all the glass came out at home but I needed stitches. Insurance denied it for a similar claim. I never punched another mirror again.
1
u/LivingGhost371 Mar 21 '25
Is this some type of student / short term insurance? I have seen contract exclusions like this on those type of policies.
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u/crazybandicoot1973 Mar 21 '25
And why should they pay for a drug related injury? So you telling me that your son wants to party and wants others to pay higher premiums so he can have fun? This should be seen as a learning moment and get him some help at your or his expense and not others.
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Mar 21 '25
[deleted]
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u/crazybandicoot1973 Mar 21 '25
You are correct, and insurance shouldn't cover it. Just like if someone is road raging of driving recklessly and cause an accident, they shouldn't be covered.
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u/SlowMolassas1 Mar 21 '25
Every single one of us does some stupid things in life. Every single one - even you.
For your sake, I hope you don't end up getting hurt while doing your own stupid things.
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u/crazybandicoot1973 Mar 21 '25
Paper towels and duct tape. I have many scars of mistakes. None involved intoxication, anger, and such. Taking drugs is a choice and not a mistake.
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u/SlowMolassas1 Mar 21 '25
Must be nice up there in your ivory tower. Hope it doesn't crumble on you one day.
13
u/Shadow1787 Mar 21 '25
Why should I have to pay for people who have children, get obese, do dangerous things ( like sports) or work in a warehouse (cancer)?
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u/Stock-Ad-2763 Mar 21 '25
If it’s a plan exclusion you won’t be able to do anything! A lot of employer plans have this as an exclusion
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u/Awkward_Ad_4456 Mar 21 '25
This is a classic case of RTFP (read the darn policy)
The vast majority of questions like this can be answered by going through the policy and seeing what is and what is not covered.
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u/hergeflerge Mar 21 '25
7k is expensive, even for an ER visit.
Go over each line of what services were billed and have the financial office explain each one.
Was there expensive imaging? Several different kinds of specialists? Did they administer drugs to counteract the ingested substances? Was he admitted to the hospital for overnight observation?
8
u/WitnessNo393 Mar 21 '25
It looks like $6,045 of the $7,835 is for code 99285. According to the internet this represents "a very high complexity emergency department (ED) visit, indicating a patient's condition requires urgent and intensive evaluation and management, involving comprehensive history, examination, and high-complexity medical decision-making"
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u/Roosterboogers Mar 21 '25
Did he sign out AMA (against medical advice)?
17
u/Expensive-Day-3551 Mar 21 '25
That has nothing to do with insurance coverage. It’s a myth that people sometimes purposefully propagate
2
u/WitnessNo393 Mar 21 '25
I am not sure but very possibly.
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u/Admirable_Height3696 Mar 21 '25
It doesn't even matter, the reason for the denial is clear and claims aren't denied because you left AMA (that is a 30 year old myth that Redditors won't let die).
5
u/sarahjustme Mar 21 '25
It way older than 30 years. Am 54, definitely remember hearing it even as a teenager. It probably was true once upon a time. You know, when someone got slapped with a $200 ER bill
1
u/laurazhobson Moderator Mar 21 '25
When I was clearing out my parents' condo after they both died I came across the bill for my grandfather's hospital stay sometime in the 1950's.
It was for cancer treatment I think and it was about $500 or so. Granted with inflation that amount would be more - according to inflation calculator it would be about $6000. But if cancer treatment in a hospital was only $6000 in 2025 there wouldn't be medical bankruptcy because that is only a bit more than some people's deductible.
Of course the trade off was that there was very little treatment available as essentially you cut out the cancerous organ or tumor and then possibly used x-rays. But there was no chemotherapy or biological drugs or MRI's or PET scans.
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Mar 21 '25
[deleted]
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u/LeadershipLevel6900 Mar 21 '25
That’s not a very smart thing to do when drugs and/or alcohol is involved. They need to know what you took in order to help you. Really, anything ingested, even if it was a plant you foraged and thought was safe.
•
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