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OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
11-0005 – March 27, 2013
Michael H. Holland, Daniel L. Fassio, 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.
Background Facts
The Complainant’s spouse sought medical treatment for dehydration, nausea, vomiting and diarrhea in the Emergency Room (ER) of a local hospital on March 24, 2012. ER records indicate the symptoms began three days earlier. Respondent denied the charges because symptoms began more than 48 hours prior to the ER visit and because the diagnosis code indicated a non-emergency condition.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on March 24, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse was having severe heart pains and immediately utilized the Emergency Room. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Position of the Respondent: Symptoms began more than 48 hours before going to the Emergency Room and no information was given at the Emergency Room that indicated heart problems.
Opinion of Trustees ROD Case No. 11-0005 Page 2
Pertinent Provisions 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.
Discussion
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 acute medical symptoms reported by Complainant had an onset of greater than 48 hours prior to Complainant’s receipt of emergency room treatment. Therefore, the charges associated with the emergency room visit are not a covered benefit under the terms of the Employer Benefit Plan.
The Funds’ Medical Director notes that Respondent’s consideration of non-emergent diagnosis discharge codes as the basis for determining the medical necessity or appropriateness of coverage of emergency medical treatment under the Employer Benefit Plan is not consistent with the terms, provisions, and requirements of the Employer Benefit Plan.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to provide benefits for Complainant’s spouse’s emergency room visit on March 24, 2012.