OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0006 – 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.
The Complainant’s spouse sought medical treatment at the local emergency room on March 25, 2012, complaining of pain and swelling of the right knee, accompanied by red streaks that Complainant’s spouse believed indicated an infection of the knee. Respondent denied the emergency room charges, stating that the patient admitted to having right knee pain for the previous two weeks and the diagnosis code indicated a non-emergency condition.
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on March 25, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse experienced acute symptoms indicating a possible infection of the knee, and utilized the Emergency Room within 24 hours of the onset of the pain, swelling and signs of infection in the right knee. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Position of the Respondent: The patient had a painful and swollen knee for two weeks, with no indication that her primary physician had been contacted. Additionally, there is no indication that the level of pain increased over the two week period prior to the time she sought treatment in the emergency room, and the discharge diagnosis indicated she was treated for a non-emergency condition.
Opinion of Trustees ROD Case No. 11-0006 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.
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’s spouse, specifically the manifest indications of a possible knee infection, had an onset of less than 48 hours prior to Complainant’s spouse’s receipt of emergency room treatment. Therefore, because the acute medical symptoms began less than 48 hours prior to the time Complainant’s spouse sought treatment at the emergency room, the charges associated with the emergency room visit are a covered benefit under the terms of the Employer Benefit Plan.
Coverage under the Employer Benefit Plan is not limited to treatment for life-threatening emergencies, as suggested by the Respondent, and the Funds’ Medical Director noted 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 required to provide benefits for Complainant’s spouse’s emergency room visit on March 25, 2012.