OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0009 – 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 daughter sought medical treatment at the local emergency room on
January 30, 2012, complaining of a sinus infection, sore throat and nose bleeds that started January 28, 2012. The emergency room physician noted that the Complainant’s daughter reported that the onset of symptoms had begun gradually two days earlier. Respondent’s Third Party Administrator denied the charges on the basis that the discharge diagnosis indicated that the Complainant’s daughter’s medical condition did not warrant emergency medical treatment according to the Respondent’s Plan. Respondent upheld the denial on appeal, and asserted further that the emergency room visit occurred more than 48 hours after the onset of symptoms, and that Complainant’s daughter could have sought treatment from her primary care physician.
Is Respondent required to provide benefits for Complainant’s emergency room visit on January 30, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter experienced acute sinusitis and nose bleeds and utilized the emergency room at a time when no other treatment facilities were available. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Opinion of Trustees ROD Case No. 11-0009 Page 2
Position of the Respondent: The Complainant’s daughter’s symptoms did not warrant emergency medical treatment, she did not go to the emergency room within 48 hours of the onset of symptoms and she could have gone to her primary care physician for treatment.
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 medical documentation does not reflect that the onset of Complainant’s daughter’s acute medical symptoms occurred within 48 hours of her visit to the emergency room on January 30, 2012, and that the emergency room physician did not document any findings of acute medical problems.
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. However, because there is no documentation of acute medical symptoms with an onset of less than 48 hours prior to the emergency room treatment on January 30, 2012, the charges associated with the emergency room visit are not 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 not required to provide benefits for Complainant’s emergency room visit on January 30, 2012.