____________________________________________________________________________
OPINION OF TRUSTEES
____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 11-0018 – 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.
Background Facts
The Complainant’s nine year-old daughter was taken to the local emergency room on March 31, 2012, complaining of a fever and cough with chest pain. Triage notes indicated a fever of 103.9 and a pulse of 181, with a headache and productive cough. Emergency room notes also state that the child had vomited the previous day. The emergency room physician’s notes mention abdominal pain, nasal congestion and a sore throat. The discharge diagnosis was exudative pharyngitis and acute sinusitis. 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 a PPO agreement that does not cover non-emergency diagnosis codes. Respondent also stated that there is no evidence that Complainant’s daughter’s primary care physician was called before she utilized the emergency room.
Dispute
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on March 31, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter had a high fever, persistent cough and headache, and utilized the emergency room at a time when no alternative treatment facility was available.
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.
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.
Discussion
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 there is no requirement in the Employer Benefit Plan to call a primary care physician for acute medical symptoms prior to seeking medical treatment at an emergency room. Also, 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 daughter’s emergency room visit on March 31, 2012.