OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0017 – 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 fourteen month-old daughter was taken to the local emergency room on April 27, 2012, with a fever of 101 degrees and report of vomiting the previous night. The emergency room physician’s examination also found a left middle ear infection that required treatment with the antibiotic Amoxicillin. The discharge diagnosis was middle ear infection. 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. Respondent also stated that the Complainant’s daughter could have been taken to her primary care physician the following morning rather than utilizing the emergency room.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on April 27, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter had a fever, had vomited, and utilized the emergency room at a time when no alternative treatment facility was available. The charges are a covered benefit under the Plan.
Position of the Respondent: The claim was not submitted with an emergency diagnosis, and the patient could have sought treatment from her primary care provider on a non-emergency basis the following morning. The denial of the claim should be upheld.
Opinion of Trustees ROD Case No. 11-0017 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 less than 48 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 April 27, 2012.