What accident insurance pays toward a high deductible: two Arizona examples

A high-deductible health plan asks you to carry the first several thousand dollars of a bad year yourself. After an accident, that can mean a stack of bills before your health plan pays much. If you live in Arizona and that is how your coverage works, the question is where that money would come from.

One answer is an accident plan. Accident ExpenseGuard, underwritten by Golden Rule Insurance Company, a UnitedHealthcare company, pays cash to you after a covered accident. The payment is based on the actual charges for your care, and it is made regardless of what your health plan pays. You can put it toward your deductible, your coinsurance or anything else.

The two examples below are fictional. One is a family hurt in the same car accident. The other is a retired man of 61 who fell from a ladder at home. The plan rules come from the carrier’s brochure.

How the payment is worked out

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

For each covered person, the payment follows three steps:

1. Take the actual charges for covered care from your health plan’s Explanation of Benefits (EOB). These are the charges after the health plan’s adjustments, discounts or allowances. Without an EOB, the plan uses what the policy calls Reasonable and Customary charges.
2. Subtract a $250 deductible. It applies per covered person per calendar year, but no more than two deductibles per family per calendar year.
3. Pay the result, up to the level chosen.

Covered services have time limits. An emergency room visit, an urgent care visit, burns or lacerations and a diagnosed concussion are covered when treatment is within 48 hours of the accident. Ambulance, labs and X-rays, anesthesia, MRI or CT scans, doctor visits, prescriptions, fractures, prosthetics, a hospital stay or ICU, and surgery are covered when treatment is within 30 days.

The brochure lists no separate rules for Arizona, and it says state-specific differences may apply. The policy is the final word.

Example one: three family members hurt in one car accident in Mesa

Ana and Hector live in Mesa with their kids, Camila, 15, and Diego, 12. Ana is a medical receptionist and Hector is a mechanic for the city’s bus fleet. Their health plan comes through Hector’s job and has a $9,000 family deductible. By February they had paid $300 of it.

Ana had bought Accident ExpenseGuard at the $7,500 level the year before, as the primary insured, and added Hector and both kids for extra premium. Each of the four had up to $7,500 of injury benefit a year.

The accident

On a Sunday evening in February, the family was driving home from a birthday dinner. At an intersection, another driver ran a stop sign and struck the passenger side of their car.

Ana’s window shattered, and she had deep cuts on her right forearm. Camila, sitting behind her, had pain in her shoulder where the seat belt had held her. Hector, who was driving, had a sore neck. Diego was shaken but not hurt.

An ambulance took Camila to the emergency room. A friend who lived nearby drove Ana, Hector and Diego there behind it. At the ER, an X-ray showed Camila had a broken collarbone. A doctor stitched Ana’s cuts. Hector had a CT scan of his neck, which showed no fracture. Over the next four weeks, Camila saw an orthopedic doctor twice, Hector saw his own doctor once, and Camila and Ana each filled a prescription for pain medicine.

Matching their care to the time limits

All three ER visits, and the treatment of Ana’s cuts, were the same evening, inside 48 hours. The ambulance, the X-rays, the CT scan, Camila’s fracture care and orthopedic visits, Hector’s doctor visit and the prescriptions were all within 30 days.

The claim

Ana gave notice of the claim that week. The policy requires notice within 30 days of the date the loss began, or as soon as reasonably possible. She sent the EOBs for each person as they arrived.

Camila:

• Ambulance: $1,350
• Emergency room visit: $1,600
• X-rays: $260
• Fracture care: $680
• Two orthopedic visits at $160 each: $320
• Prescription: $20
• Total: $4,230

Ana:

• Emergency room visit: $1,150
• Repair of the cuts: $480
• Prescription: $30
• Total: $1,660

Hector:

• Emergency room visit: $1,050
• CT scan: $890
• Doctor visit: $140
• Total: $2,080

The arithmetic, person by person

Each covered person has their own deductible and their own maximum, but the family pays no more than two deductibles in a calendar year.

Camila. $4,230 minus her $250 deductible is $3,980. That is under her $7,500 maximum. Paid: $3,980.

Ana. $1,660 minus her $250 deductible is $1,410. That is under her maximum. Paid: $1,410.

Hector. Two deductibles had now been taken for the family that year, so none applied to Hector. His $2,080 is under his maximum. Paid: $2,080.

Accident ExpenseGuard paid $7,470 in all ($3,980 plus $1,410 plus $2,080), directly to Ana.

What each person had left for the year: Camila, $3,520. Ana, $6,090. Hector, $5,420. Diego, the full $7,500. And no more deductibles would apply to anyone in the family until January.

Putting it against their deductible

The family’s covered charges came to $7,970 ($4,230 plus $1,660 plus $2,080). With $8,700 of their $9,000 family deductible still ahead of them, they owed all of it.

• What they owed for the accident: $7,970
• What Accident ExpenseGuard paid: $7,470
• The difference: $500, the two $250 deductibles.

The other driver’s auto insurance was a separate matter. The brochure says this plan pays regardless of benefits paid by other insurance, so Ana did not wait on the auto claim to file.

What the plan did not pay

Hector’s later care. His neck stayed stiff, and in the sixth week he started seeing a chiropractor. That care began more than 30 days after the accident, and chiropractic care is not among the services the brochure lists. The family paid for it under their health plan.

The car. Repairs and a rental car are not medical charges, so they were outside the plan.

Driving for pay. Hector sometimes drives for a rideshare service on weekend evenings. The policy excludes operating a taxi or any other passenger transportation service for wage, compensation or profit. If the crash had happened during one of those shifts, this plan would not have paid.

Intoxication. The policy also excludes a loss while a covered person is intoxicated, as defined by applicable state law.

Example two: a fall from a ladder at home in Prescott

Howard is 61 and lives in Prescott with his wife, Joyce. He retired two years ago after a career as a mail carrier, and Joyce still works part time at a garden center. They buy their own health insurance. Each of them has a $5,900 deductible, then 25% coinsurance up to an $8,600 out-of-pocket maximum.

Howard applied for Accident ExpenseGuard at 59, within the 18-to-64 age range for applying, as the primary insured. He added Joyce for extra premium and chose the $15,000 level, well above the most either of them could owe under their health plan in a year.

The fall

On a Saturday morning in November, Howard was on a ladder clearing pine needles out of the gutters. The ladder’s feet slid on the patio, and he fell about eight feet. He landed on his left foot and caught himself with his right hand.

Joyce called 911, and an ambulance took him to the emergency room. X-rays and a CT scan showed a badly broken heel and a broken right wrist. The ER put a splint on his wrist, which an orthopedic doctor set in a cast the next day. On day 3, a surgeon repaired the heel with plates and screws, under anesthesia. Howard was in the hospital for two nights, went home with prescriptions and saw the surgeon on day 13 and day 27.

Matching his care to the time limits

His emergency room visit was the same morning, inside 48 hours. The ambulance, the imaging, the wrist fracture care, the heel surgery, the anesthesia, the hospital stay, the prescriptions and both follow-up visits were all within 30 days.

The claim

Joyce gave notice of the claim from the hospital, well inside the 30 days the policy allows. Howard sent the claim form with the EOBs as they came in. The actual charges after their health plan’s adjustments:

• Ambulance: $1,500
• Emergency room visit: $1,900
• X-rays and CT scan: $1,350
• Heel surgery: $12,400
• Wrist fracture care and cast: $850
• Anesthesia: $1,700
• Two-night hospital stay: $6,200
• Prescriptions: $90
• Two follow-up visits at $185 each: $370

Total actual charges after adjustments: $26,360.

The arithmetic

Step 1. Start with the actual charges: $26,360.

Step 2. Subtract the $250 deductible: $26,360 minus $250 is $26,110.

Step 3. Apply the maximum. Howard’s benefit is up to $15,000 for the calendar year. $26,110 is more than that, so the payment stops at $15,000.

Accident ExpenseGuard paid $15,000, directly to Howard.

He had used his full benefit for the year. It starts over in January. Joyce still had her full $15,000.

Putting it against his deductible

On his health plan, the same $26,360 worked out like this:

• His deductible: $5,900
• 25% coinsurance on the remaining $20,460: $5,115
• That adds up to $11,015, more than his $8,600 out-of-pocket maximum.
• What he owed: $8,600, the maximum.

The $15,000 covered the $8,600 and left them $6,400. Howard could not drive or climb stairs for two months, so they used it for rides to appointments, a handyman to finish the gutters and fix the porch step, and grocery delivery while Joyce was at work.

What the plan did not pay

His knee scooter and walker. The policy excludes durable medical equipment.

His occupational therapy. After the cast came off, Howard worked with an occupational therapist on his grip and wrist. The policy excludes occupational therapy.

Anything above $15,000. His charges after the deductible were $26,110, which is $11,110 more than his maximum. His health plan handled its share of that under its own terms.

Paid odd jobs. Howard sometimes does small repairs for neighbors for cash. If he had fallen from a ladder on one of those jobs, the policy’s exclusion for an injury arising out of, or in the course of, employment for wage or profit would have applied.

Illness. If a stroke had caused the fall, the policy’s exclusion for any cerebrovascular accident would apply. It is an accident plan, not a health plan.

Matching a benefit level to your own deductible

These two households chose levels for different reasons, and both choices worked out for the accident they had. A different accident could have played out differently.

A family’s deductible is shared. The plan’s level is not. Ana and Hector’s $9,000 deductible covered all four of them. Their $7,500 level was per person, so three people’s claims together paid $7,470 against $7,970 in bills. A single person’s level does not need to match a family deductible for a family claim to cover most of it.

The two-deductible limit helps when several people are hurt. In the Mesa crash, the third person’s claim paid with no deductible at all.

A larger level can cover more than medical bills. Howard chose $15,000 to sit well above his $8,600 out-of-pocket maximum. At $10,000, the plan would still have covered it, with $1,400 left over. At $7,500, he would have been $1,100 short. His extra $5,000 above the $10,000 level went to help at home. The level is one of the factors in the premium, and whether the extra is worth it is a personal call.

Some questions to ask:

What do you owe before your health plan pays in full? Your deductible and out-of-pocket maximum are the numbers to compare with the levels.

Who is most likely to get hurt? Every covered person has their own yearly maximum. Adding a spouse or children costs extra premium. Children can be covered from birth to 25 and drop off on their 26th birthday, or as required by state.

How old are you? The primary insured and spouse must be 18 to 64 at the time of application. The policy is renewable until the primary insured’s 70th birthday, subject to its terms.

Where would you get hurt? The policy does not cover an injury arising out of, or in the course of, employment for wage or profit. If most of your risk is on the job, look at coverage built for that.

What it is not. Accident ExpenseGuard is a supplement. It is not major medical coverage, not Minimum Essential Coverage, and not a substitute for comprehensive health insurance.

The short version

After a car accident in Mesa, Accident ExpenseGuard paid a family $7,470 for three people’s injuries, leaving them $500 of $7,970 in bills that fell inside their deductible. After Howard’s fall from a ladder in Prescott, it paid him $15,000, enough for his $8,600 out-of-pocket maximum with $6,400 left for help at home. It did not pay for equipment, therapy, care past 30 days or the car.

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