Complainant: Respondent: ROD Case No:
11-0032 – June 12, 2014
To: Michael H. Holland, Marty D. Hudson, and Daniel R. Jack
The facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan have been reviewed.
The Complainant sought medical treatment at the local emergency room on May 28, 2012, complaining of a severe and worsening headache with high blood pressure. He was discharged with instructions to follow up with his primary care physician. On June 3, 2012, the Complainant returned to the emergency room complaining of localized facial numbness. Emergency room records indicate that the numbness was limited to a small area at the left corner of his mouth and had not progressed since onset. It was also noted that the Complainant had not followed up with his primary care physician or contacted him over the 4-5 days since the numbness had begun. No other neurological symptoms were present and a CT scan was normal.
Respondent approved the charges associated with the May 28, 2012 visit to the emergency room, but denied the June 3, 2012 charges, asserting that this was a non-emergency.
Is Respondent required to provide benefits for Complainant’s emergency room visit on June 3, 2012?
Positions of the Parties
Position of the Complainant: The Complainant was experiencing facial numbness and went to the emergency room. This was a Sunday and the emergency room was the only available location for treatment. The charges are a covered benefit under the Employer Benefit Plan.
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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.
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.(3)(h) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care (h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, if provided by a physician.
Article III.A.(3)(j) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care (j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
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 had been experiencing the problem for which he sought emergency room treatment for the previous 4 – 5 days, he had not sought treatment from his primary care physician. Aside from the numbness, no other
ROD Case No. 11-0032 Page 3
neurological symptoms were present. The Funds’ Medical Director opined that because the symptoms had an onset of more than 48 hours prior to the emergency room treatment, they are not a covered benefit under the terms of the Employer Benefit Plan.
The physicians’ charges and CT scan are covered benefits under Article III.(A)(3)(h) and (j) 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.
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to provide benefits for Complainant’s emergency room visit on June 3, 2012, totaling $499.00. The Employer is responsible for the remaining physicians’ charges and radiological studies totaling 1,053.80.