Coverage of Emergency Services

August 15, 2002

Memorandum 2002-7A

TO:

All Licensed Motor Vehicle Insurers in the State of Hawaii

FR:

Wayne Metcalf

Insurance Commissioner

RE:

Coverage of Emergency Services

Questions have recently arisen concerning the definition of “emergency services” and what

constitutes an “emergency medical condition” in the adjustment of personal injury protection ("PIP")

claims. Please note that §431:10C-103, Hawaii Revised Statutes ("HRS"), provides guidance on this

matter:

""Emergency medical condition” means a medical condition that manifests itself

by acute symptoms of sufficient severity, including severe pain, 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:

(1)

Placing the health of the individual, including the health of a pregnant

woman or her unborn child, in serious jeopardy;

(2)

Serious impairment to bodily functions; or

(3)

Serious dysfunction of any bodily organ or part.

"Emergency services" means:

(1)

A medical screening examination, if required by federal law, that is within the

capability of the emergency department of a hospital, including ancillary

services routinely available to the emergency department, to evaluate

an emergency medical condition; or

(2)

Further medical examination and treatment, if required by federal law, that is

within the capabilities of the staff and facilities available at the hospital, including

uired by federal law, that is within the

capability of the emergency department of a hospital, including ancillary

services routinely available to the emergency department, to evaluate

an emergency medical condition; or

(2)

Further medical examination and treatment, if required by federal law, that is

within the capabilities of the staff and facilities available at the hospital, including

Memorandum 2002-7A

August 15, 2002

Insurance Commissioner Wayne Metcalf

State of Hawaii

Page 2

any trauma and burn center of the hospital to stabilize an emergency medical

condition. (Emphasis added)

“Stabilize" means the provision of medical treatment as may be necessary to

assure, within reasonable medical probability, that no material deterioration of an

individual’s medical condition is likely to result from or occur during a transfer to

another facility, if the medical condition could result in placing the health of the individual

or the health of a pregnant woman or her unborn child in serious jeopardy, serious

impairment to bodily functions, or serious dysfunction of any bodily organ or part."

PIP claims, therefore, shall be adjusted in accordance with the above definitions and in

accordance with applicable provisions of the Title 16, Chapter 23, Hawaii Administrative Rules

("HAR"). Charges and treatment rendered for emergency services during the initial seventy-two hours

following the motor vehicle accident resulting in injury shall not be subject to HAR Subchapter 17,

Chapter 23, Title 16.

However, the charges for emergency treatment shall not exceed the health care or alternative

care provider’s usual and customary fee and shall be appropriate, reasonable, and necessarily incurred.

Charges for treatment of a primarily palliative nature shall be subject to the requirements of HAR

Subchapter 17, Chapter 23, Title 16, in the same manner as any other treatment

pter 23, Title 16.

However, the charges for emergency treatment shall not exceed the health care or alternative

care provider’s usual and customary fee and shall be appropriate, reasonable, and necessarily incurred.

Charges for treatment of a primarily palliative nature shall be subject to the requirements of HAR

Subchapter 17, Chapter 23, Title 16, in the same manner as any other treatment.

Should further clarification be needed, please contact the Insurance Division at the above

address or at (808) 586-2790.