OPINION OF TRUSTEES
ROD Case No: 07-0025 – April 29, 2009
Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Complainant’s spouse presented to the Emergency Room (ER) on January 17, 2008, after developing a severe headache while en route to visit a relative. The diagnosis was acute headache. Respondent has denied the charges associated with the ER visit as being not medically necessary.
Is the Respondent required to provide benefits for the emergency room charges resulting from the ER visit by the Complainant’s spouse on January 17, 2008?
Positions of the Parties
Position of the Complainant: Respondent is required to provide benefits for the ER visit because emergency care was medically justified and sought within 48 hours of the acute onset of symptoms.
Position of the Respondent: The level of care provided by the ER was not medically necessary in this instance. Additionally, the ER visit occurred at mid-day on a week day when other options for medical treatment were available.
Article III. A. (2)(a) of the Employer Benefit Plan states:
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provide for a Beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
The spouse of the Complainant states that the headache experienced at the time of the ER visit was the worst pain she had ever had. In the weeks just prior to this incident, she had also experienced blood pressure readings abnormally high for her and this, coupled with the head pain, led her to fear she might be having a stroke. The ER nursing record indicates nausea and neck pain in addition to elevated blood pressure.
In the denial, the Respondent referred to the classification “non-urgent” in the triage section of the Emergency Nursing Record as a reason to deny benefits. The Funds’ Medical Director has reviewed the file, including the ER records, and has determined it was the triage nurse, not the attending physician, who circled “non-urgent” as part of the triage system to indicate that the patient did not need to be seen immediately by the ER physician. It is a subjective designation and is not meant to indicate that a person does not require emergency care. Funds’ Medical Director noted that her history and symptoms were enough for the ER physician to recommend an emergency CT scan and an MRI of the brain to rule out potentially life-threatening problems.
It is the opinion of the Funds’ Medical Director that the documentation is consistent with a severe event with an acute onset measured in hours, and that the ER visit was medically necessary.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Respondent is required to provide benefits for the January 17, 2008, ER visit by the spouse of the Complainant.