Complainant: Respondent: ROD Case No:
07-0072 – October 25, 2014
To: Michael H. Holland, Marty D. Hudson, Daniel R. Jack, and Michael McKown
The facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan have been reviewed.
Complainant sought medical treatment at an emergency room on December 24, 2010, while visiting relatives in another state. At the emergency room, Complainant complained of pain in his right great toe that radiated to his ankle and could not bear weight on his right foot. The emergency room records indicate that Complainant’s symptoms began at least three days prior to, and were acute on the date of, his emergency room visit. However, the emergency room records do not indicate when Complainant’s symptoms became acute. Complainant was ultimately diagnosed with acute gout and discharged.
Respondent’s third-party administrator denied payment for the emergency room charges because, it argued, Complainant experienced symptoms for three days before visiting the emergency room and the records did not indicate acute worsening or dangerous symptoms that demonstrated the need to receive care immediately in an emergency room setting.
Is Respondent required by the terms of the Employer Benefit Plan to provide benefits for Complainant’s emergency room visit on December 24, 2010?
Positions of the Parties
Position of the Complainant: Respondent is required to provide benefits for Complainant’s emergency room visit on December 24, 2010, because Complainant had the symptoms less than 24 hours prior to his emergency room visit.
ROD Case No. 07-0072 Page 2
Position of the Respondent: Respondent has not responded to requests for its position regarding the emergency room charges.
Pertinent Provisions 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.
Article III.A(2)(a) of the Employer Benefit Plan provides benefits for emergency medical treatment if the emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms. The Funds’ Medical Director reviewed the file, including the emergency room records, and determined that the clinical evidence indicates Complainant received emergency services within 48 hours after the onset of acute medical symptoms. Given that Complainant received emergency medical treatment within 48 hours following the onset of acute medical symptoms, the charges associated with Complainant’s emergency room visit are covered under the terms of the Employer Benefit Plan.
Under the terms of the Employer Benefit Plan, Respondent is required to provide benefits for Complainant’s emergency room visit on December 24, 2010.