OPINION OF TRUSTEES
ROD Case No: 11-0023 – 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 six year-old son was taken to the local emergency room on March 25, 2012, complaining of a sore throat that began ten days earlier, and a fever of three days’ duration. Medical records indicate the child’s temperature was 100.0 degrees F and that the child had been taking Amoxicillin twice a day for five days without improvement. The Emergency Room records do not document any recent medical symptoms or physical findings. Respondent’s Third Party Administrator denied the charges and Respondent upheld the denial on the basis that the child had had a sore throat for ten days and 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 March 25, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s son’s symptoms were acute and there was no alternate treatment facility available that day because it was a Sunday. The charges are a covered benefit under the Plan.
Position of the Respondent: The claim was not submitted with an emergency diagnosis and therefore the denial of the claim should be upheld.
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 medical symptoms reported by Complainant’s son did not warrant emergency room treatment. Therefore, the charges associated with the emergency room visit are not 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 not required to provide benefits for Complainant’s son’s emergency room visit on March 25, 2012.