OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0010 – 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 March 27, 2012, complaining of bi-lateral burning and pain in her eyes that began in the 24 hour period prior to the time she sought treatment in the emergency room. Respondent denied the emergency room charges, stating that Complainant’s daughter had been treated two weeks earlier for a similar problem and could have sought treatment from her primary care provider on a non-emergency basis.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on March 27, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter was experiencing painful, burning eyes that she could not open, and utilized the Emergency Room. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Position of the Respondent: The patient could have sought treatment from her primary care provider on a non-emergency basis since the symptoms were a reoccurrence of those she had experienced two weeks earlier.
Opinion of Trustees ROD Case No. 11-0010 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 daughter had an onset of 24 hours prior to Complainant’s daughter’s receipt of emergency room treatment. Therefore, the charges associated with the emergency room visit are 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. The Funds’ Medical Director also notes that there is no requirement in the Employer Benefit Plan that a beneficiary see a personal care physician for acute medical symptoms prior to seeking emergency room medical treatment.
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 daughter’s emergency room visit on March 27, 2012.