OPINION OF TRUSTEES
ROD Case No: 11-0022 – 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 nine year-old daughter sought medical treatment at the local emergency room on February 12, 2012, complaining of burning on urination and abdominal pain of one day’s duration, and a cough of four weeks’ duration. 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 February 12, 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 diagnosis on this claim was not for an emergency situation.
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 the Complainant’s daughter had an onset of less than 24 hours prior to her receipt of emergency room treatment.
The appeal response from the Respondent referenced the medical policy relied on by the Third Party Administrator to base its denial decision. That policy set forth the “prudent layperson’s definition of emergency care.” The Funds’ Medical Director states that “[t]his definition was developed and accepted nationally in an attempt to prevent patients from being denied emergency care coverage when ‘a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that not seeking immediate medical care could result in serious impairment to bodily function or serious dysfunction to a bodily organ or part.’” The Funds’ Medicare Director noted that this definition was adopted “to prevent denial of emergency treatment based on a discharge diagnosis after medical evaluation that neither a lay person nor a physician can be sure is non emergent without a medical evaluation.” The Funds’ Medical Director went on to note that the prudent layperson definition of emergency care is not part of the emergency treatment criteria of the Employer Benefit Plan.
Therefore, because the acute medical symptoms in this case had an onset of less than 48 hours prior to the time that the Complainant’s daughter sought 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 February 12, 2012.