OPINION OF TRUSTEES
ROD Case No: 11-0003
Trustees: Michael H. Holland, Daniel L. Fassio, Kurt A. Salvatori, and
Marty D. Hudson
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 brought his three-year-old son to a hospital emergency room on February 3, 2012, at 1:46 a.m., after the child developed a fever and began coughing and vomiting. Complainant stated that his son’s symptoms began gradually the previous day, and the child’s temperature was documented at 104.1, 104.3 and 103.6 degrees Fahrenheit during his emergency room visit. The emergency room physician diagnosed Complainant’s son with fever and respiratory syncytial virus and discharged him at 2:36 a.m. Respondent has denied the claim for the emergency room visit.
Is Respondent required to provide benefits for Complainant’s son’s emergency room visit on February 3, 2012?
Positions of the Parties
Position of the Complainant: The child’s temperature was sufficiently high to constitute an emergency. Therefore, Respondent should cover the emergency room charges pursuant to Article III.A(2)(a) of the Employer Benefit Plan.
Position of the Respondent: Respondent has not provided a response in this ROD.
Article III.A(2)(a) of the 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 child’s symptoms were acute and that his acute symptoms began within 24 hours of the emergency room treatment. Therefore, the charges associated with the child’s emergency room visit are a covered benefit under the terms of the Employer Benefit Plan.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is required to provide benefits for Complainant’s son’s emergency room visit on February 3, 2012.