OPINION OF TRUSTEES
ROD Case No: 11-0015 – March 27, 2013
Trustees: 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 fifteen month-old daughter was taken for medical treatment to the local emergency room on May 16, 2012, because of hard coughing that awoke the infant from her nap earlier that day, and a runny nose and sneezing that started the previous evening. Respondent’s Third Party Administrator denied the charges and Respondent upheld the denial 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 Third Party Administrator’s guidelines.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on May 16, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter experienced acute symptoms and utilized the emergency room within 24 hours of the onset of those symptoms. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Position of the Respondent: The discharge diagnosis does not indicate that Complainant’s daughter was treated for an emergency medical condition and therefore she is not entitled to coverage under the Employer Benefit Plan.
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 onset of Complainant’s daughter’s acute medical symptoms occurred within the 48 hour period prior to her receipt of emergency room treatment.
The Funds’ Medical Director noted that the appeal responses from the Respondent referenced non-compliance with the terms of a PPO agreement and the discharge diagnosis as the bases for the denial of Complainant’s claim for benefits. The Funds’ Medical Director also went on to note that “[t]here are no such provisions for denying emergency care within Article III of the Employer Benefit Plan.” The Funds’ Medical Director observed that “one cannot expect a lay person going for emergency care to know if their [child’s] acute symptoms are going to lead to an emergent or non emergent diagnosis.”
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.
Therefore, because the acute medical symptoms had an onset of less than 48 hours prior to the time the Complainant’s daughter received 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.
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 May 16, 2012.