OPINION OF TRUSTEES
ROD Case No: 11-0024 – August 6, 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 17 year-old daughter sought medical treatment at the local emergency room on April 17, 2012, complaining of abdominal pain since the early morning hours prior to her admission to the emergency room. Emergency room notes indicate that the Complainant’s daughter rated the pain as 8 out of 10, had abdominal tenderness upon examination, and that a urinalysis was compatible with an early urinary tract infection. The treating physician concluded that the abdominal pain was likely due to mid menstrual cycle ovulation. 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 and that the emergency room visit occurred during office hours.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on April 17, 2012?
Positions of the Parties
Position of the Complainant: The Complainant sought treatment at the emergency room for severe abdominal pain. The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: The diagnosis does not indicate an emergency situation, and the Complainant could have sought treatment with her primary physician. The denial of charges 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 Complainant’s daughter’s symptoms had an onset within 48 hours of her visit to the emergency room, and were acute enough to warrant urgent medical evaluation and treatment. Therefore, the charges associated with the visit to the emergency room on April 17, 2012, are a covered benefit under the terms of the Employer Benefit Plan.
The Funds’ Medical Director also noted 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.
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 17, 2012.