____________________________________________________________________________
OPINION OF TRUSTEES
____________________________________________________________________________
In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 07-0063 – December 15, 2011
Trustees: Micheal W. Buckner, Daniel L. Fassio, Morris D. Feibusch, and Michael
H. Holland.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
Complainant’s spouse sought medical treatment for vaginal bleeding, on the same day that this symptom began, in the emergency room of a local hospital on January 29, 2011. Prior to the onset of this symptom, she had been experiencing other symptoms, including vaginal itching and burning, for three days.
Respondent denied the emergency room charges after determining that the diagnosis was not sudden or serious and that treatment was not rendered within 48 hours following the onset of acute medical symptoms.
Dispute
Is the Employer required to cover the emergency room charges under the terms of the Employer Benefit Plan?
Positions of the Parties
Position of the Complainant: Complainant’s spouse sought emergency room treatment for the vaginal bleeding less than 48 hours following its onset, and, therefore, the Employer is required to cover the emergency room charges under the terms of the Employer Benefit Plan.
Position of the Respondent: The symptoms of Complainant’s spouse were not sudden or serious, and she did not seek treatment until more than 48 hours following their onset. Therefore, Respondent is not required to cover the emergency room charges under the terms of the Employer Benefit Plan.
Pertinent Provisions
Article III of the 2007 Employer Benefit Plan states in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care . . . Services which are not reasonable and necessary shall include, but are not limited to . . . procedures which can be performed with equal efficiency at a lower level of care.
Article III.A(2)(a) of the 2007 Employer Benefit Plan states:
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provided 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.
Discussion
Article III of the Employer Benefit Plan provides benefits for emergency medical treatment rendered within 48 hours following the onset of acute medical symptoms.
The Funds’ Medical Director has reviewed the medical records submitted in this ROD and has determined that the vaginal bleeding began four hours prior to Complainant’s spouse’s emergency room visit, Complainant’s spouse’s symptoms were acute and, therefore, the emergency room charges are covered under the terms of the Employer Benefit Plan.
Opinion of the Trustees
Under the terms of the Employer Benefit Plan, Respondent is required to provide benefits for the emergency room charges of January 29, 2011.