____________________________________________________________________________
OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Pensioner
Employer
11-0031 – April 24, 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.
Background Facts
The Complainant’s spouse sought medical treatment at the local emergency room on February 6, 2012, complaining of severe left side facial and dental pain radiating into the maxillary sinus. Emergency room records indicate the pain was in the area of a crown inserted a year earlier that had caused intermittent problems since the dental work was performed. The pain was treated with an intramuscular injection of Demerol and narcotic pills were dispensed to be taken four times a day as needed. The Complainant’s spouse was given a referral to see her dentist later that day, and her dentist further treated the pain with steroids and an antibiotic to be taken with pain pills as needed. Respondent has denied the charges associated with the visit to the emergency room, asserting that this was a non-emergency.
Dispute
Is Respondent required to provide benefits for Complainant’s emergency room visit on February 6, 2012?
Positions of the Parties
Position of the Complainant: The Complainant was experiencing extreme pain that occurred on the day treatment was sought. The charges are a covered benefit.
Position of the Respondent: The claim was not submitted with an emergency diagnosis and is not a covered benefit. The denial of the claim should be upheld.
Opinion of Trustees ROD Case No. 11-0031 Page 2
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 although the Complainant’s spouse had been having intermittent problems with a crown on the left side over a one year period, the pain she experienced during the evening of February 5, 2012 or the early morning hours of February 6, 2012, precipitating her visit to the emergency room, was of such severity that it required an injection of a strong dose of narcotic medication as well as narcotic pain pills to suppress the pain so she could see her dentist later the same day. The acute medical symptoms experienced by the Complainant’s spouse had an onset of less than 48 hours prior to the time she sought treatment at the local emergency room on February 6, 2012, and are a covered benefit under the terms of the Employer Benefit Plan.
The Funds’ Medical Director notes 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 spouse’s emergency room visit on February 6, 2012.