OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0021 – 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 twenty-one year old son went to the local emergency room on June 20, 2012, complaining of difficulty walking, pain in his right great toe, the pain registering eight out of ten, and with the nail of the toe split from an injury the previous day. Medical records indicate the toe nail was ingrown and swollen with abnormal redness. The emergency physician removed half the lower nail and the nail bed and placed the Complainant’s son on antibiotics for the infection. The Complainant’s wife alleges that she tried to locate a podiatrist for treatment and was referred to the Emergency Room by the on call primary care physician. 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 son’s medical condition did not warrant emergency medical treatment.
Is Respondent required to provide benefits for Complainant’s son’s emergency room visit on June 20, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s son’s toe was swollen, painful and infected, and required surgical treatment. The charges are a covered benefit under the Plan.
Opinion of Trustees ROD Case No. 11-0021 Page 2
Position of the Respondent: The claim was not submitted with an emergency diagnosis, and therefore the denial of the claim should be upheld.
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 son had an onset of less than 48 hours prior to Complainant’s son’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.
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 son’s emergency room visit on June 20, 2012.