How accident insurance helped a family after a child's broken arm

Marisol and Dev live in Las Vegas with their two kids, Mateo, 11, and Nina, 8. Marisol is a dental hygienist. Dev manages a print shop. Their health insurance comes through Dev’s job, and it is a good plan, but it has a family deductible they rarely meet before the end of the year.

That deductible was the reason they looked at accident insurance. Their kids play soccer on weekends, ride bikes and climb on everything. The family had never had a big medical bill, but they had done the math on what one trip to the emergency room could cost before their health plan started paying.

This story follows them through one year with Accident ExpenseGuard, an accident plan underwritten by Golden Rule Insurance Company, a UnitedHealthcare company. It shows what the plan paid, how the payment was worked out and what it did not cover.

What they chose

Accident ExpenseGuard has two parts.

• An accidental injury benefit. You choose an amount: $5,000, $7,500, $10,000, $15,000 or $20,000. That is the most the plan pays per covered person per calendar year. It starts over each year.
• An accidental death and dismemberment (AD&D) benefit. It matches the injury amount you choose and is a lifetime maximum per covered person.

Marisol and Dev chose the $10,000 level. Marisol applied as the primary insured and added Dev, Mateo and Nina. Adding dependents costs extra premium, and they decided covering all four of them was worth it.

They read two rules closely before signing up.

The deductible. Before the plan pays for an accidental injury, there is a $250 deductible per covered person per calendar year, up to two deductibles per family per calendar year. In a family of four, the most they would pay in deductibles in one year is $500.

The payment. Accident ExpenseGuard does not coordinate with other insurance. It pays the insured directly, whatever their health plan pays. To work out the payment, the plan looks at the Explanation of Benefits (EOB) from their health insurance. The EOB shows the actual charges after the health plan’s adjustments, discounts or allowances. Those actual charges, minus the deductible, are what the plan pays, up to the yearly maximum. If there is no EOB, the plan uses what the policy calls Reasonable and Customary charges, based on the most common charge for similar services in the area.

A Saturday game

In April, Mateo’s recreational soccer league played on a Saturday morning. Late in the second half, he went up for a header, collided with another player and landed hard on his right arm. He got up holding his wrist, and it was already swelling.

Dev drove him straight to the emergency room. An X-ray showed a broken forearm. The emergency doctor put on a splint and referred them to an orthopedic doctor. Mateo saw the specialist three days later and got a cast. Over the next four weeks he had two follow-up visits and one more X-ray to check how the bone was healing. He also had a prescription for pain medicine for the first few days.

Mateo was fine, if annoyed about missing the rest of the season. Marisol took two unpaid days off work, one for the first orthopedic visit and one when the school called because his arm was bothering him.

Matching the visits to the plan’s time limits

Accident ExpenseGuard lists covered services along with how soon after the accident treatment has to happen.

Treatment within 48 hours:

• Burns or lacerations
• Diagnosed concussion
• Emergency room visit
• Urgent care center visit

Treatment within 30 days:

• Ambulance
• Labs and X-rays
• Anesthesia services
• MRI or CT scan
• Doctor visits
• Prescriptions
• Fractures
• Prosthetics
• Hospital stay or ICU
• Surgery

Mateo’s ER visit was the same day, inside the 48-hour window. The fracture care, the follow-up visits, the X-rays and the prescription all happened within 30 days of the game. The time limits can differ in some states, so the policy is the place to check.

The claim

The policy requires notice of claim within 30 days of the date the loss began, or as soon as reasonably possible. Marisol gave notice the week after the game, then waited for the EOBs from their health plan so she could send them in with the claim form.

The bills from the hospital and the doctors added up to $5,640 before the health plan’s network discounts. That is not the number Accident ExpenseGuard uses. It uses the actual charges on the EOB, after adjustments. Here is what the EOBs showed:

• Emergency room visit: $1,240
• X-rays at the ER: $310
• Fracture care and casting: $1,150
• Two follow-up doctor visits at $180 each: $360
• Follow-up X-ray: $95
• Prescription: $25

Total actual charges after adjustments: $3,180.

The arithmetic

Step 1. Start with the actual charges: $3,180.

Step 2. Subtract Mateo’s $250 deductible for the year: $3,180 minus $250 is $2,930.

Step 3. Check the maximum. Mateo’s accidental injury benefit is up to $10,000 for the calendar year. $2,930 is under that, so nothing is cut off.

Accident ExpenseGuard paid $2,930, directly to Marisol.

After this claim, Mateo had $7,070 of accidental injury benefit left for the year ($10,000 minus $2,930). Marisol, Dev and Nina each still had their full $10,000. In January, everyone’s amount starts over.

Why the billed total didn’t set the payment

It is easy to look at the first bills and expect the plan to pay on those. It does not. The bills totaled $5,640, but the payment was worked out from $3,180, the actual charges after the health plan’s network adjustments. If the plan had used the billed amounts, the math would have been different, and that is not how the policy works.

This is why the EOB matters so much. It is the document that shows what the providers actually charged once discounts and allowances were applied. Without an EOB, the plan would use Reasonable and Customary charges instead, which the policy bases on the most common charge for similar services in the area where the charge was incurred.

The practical lesson for the family was simple: keep every EOB, match it to the right accident, and send it in with the claim form.

Where the money went

The plan pays the insured, not the hospital, and the money can be used as the family sees fit.

Their health plan’s family deductible had barely been touched that year, so most of Mateo’s charges landed on them. Marisol used the $2,930 to pay down the bills from the ER and the orthopedic office. The rest went toward the two days of pay she gave up.

The payment did not depend on what their health plan paid or did not pay. If the health plan had covered most of the charges, Accident ExpenseGuard would have paid the same $2,930, because it is based on the actual charges, not on what is left over.

A second accident, and the family deductible limit

In November, Dev cut his hand badly while slicing bread. He went to an urgent care clinic that evening and got stitches. A laceration and an urgent care visit are both on the 48-hour list, and he was seen within hours.

The EOB showed actual charges of $420.

Step 1. Actual charges: $420.

Step 2. Subtract Dev’s $250 deductible: $420 minus $250 is $170.

Step 3. Dev’s maximum is $10,000 for the year, so the full $170 is payable.

Accident ExpenseGuard paid $170.

That was the family’s second $250 deductible of the year. Because the deductible applies up to two per family per calendar year, if Nina or Marisol had been hurt in December, no further deductible would have applied for the rest of that year. In January, the count starts again.

What the plan did not do

The plan was useful, but it has limits, and the family ran into some of them.

It did not pay for occupational therapy. After the cast came off, Mateo’s doctor suggested a few sessions of occupational therapy to help with his grip. The policy excludes outpatient speech therapy and occupational therapy. Those sessions went through their health plan only.

It did not pay for durable medical equipment. The policy excludes durable medical equipment. Items like crutches, a wheelchair or a walker are not paid by this plan.

It does not cover every kind of sport. Mateo’s league is recreational, which the policy does not exclude. The policy does exclude injuries while taking part in semi-professional, professional or intercollegiate sports (intramural sports are not part of that exclusion). It also excludes some activities altogether, such as parachute jumping, hang gliding, skydiving and bungee jumping. If your child plays at a competitive level, ask how the policy treats it.

It does not cover infections. The policy excludes infections of any kind, regardless of how they were contracted. If Dev’s cut had become infected, treatment for the infection would not have been covered.

It does not pay for illness. This is an accident plan. Sickness, a stroke or anything that is not an accidental injury is outside it.

It is not health insurance. Accident ExpenseGuard is a supplement. It is not major medical coverage, it is not Minimum Essential Coverage, and it is not a substitute for comprehensive health insurance. Marisol and Dev kept their health plan, and it did the heavy lifting for Mateo’s care. Accident ExpenseGuard helped with the part their health plan left to them.

It has a ceiling. Each covered person’s injury benefit is capped at the amount chosen, here $10,000 per calendar year. A serious accident can cost more than that.

Is family accident coverage right for you?

There is no single answer, but these questions can help.

What is your health plan’s deductible? If your family would pay several thousand dollars before your health plan pays much, a plan that pays on actual charges can help fill that gap.

How active is your household? Accident coverage is about injuries, not illness. Think about what your family actually does on a typical weekend.

Can you cover the deductible? Each covered person pays the first $250 of covered charges each calendar year, with up to two deductibles per family. Small injuries under $250 will not produce a payment.

Which benefit level fits? The levels run from $5,000 to $20,000 per covered person per year. A higher level means a higher maximum and a matching higher AD&D amount, and it changes the premium.

Who should be covered? The primary insured and spouse must be 18 to 64 at the time of application. Children can be covered from birth up to age 25 and drop off on their 26th birthday, or as required by state. Each dependent adds premium.

Are you ready for the paperwork? The plan works from your health plan’s EOB. Keep your EOBs, give notice of a claim within 30 days, and send the EOB with the claim form.

The short version

For this family, Accident ExpenseGuard paid $2,930 after Mateo’s broken arm and $170 after Dev’s cut hand: $3,100 for the year, paid to them directly, on top of what their health plan paid. It did not cover therapy, equipment or anything outside its list, and it never replaced their health insurance.

This is an outline of how the plan works. The policy itself sets the full terms, including the exclusions and any state-specific differences.