OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0034 – March 27, 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.
The Complainant sought medical treatment at the local emergency room on April 22, 2012, complaining of a mildly itchy rash under his right arm and armpit and his left wrist.
Emergency room notes indicate that the Complainant had cut bushes the previous day. 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 medical condition did not warrant emergency medical treatment.
Is Respondent required to provide benefits for Complainant’s emergency room visit on April 22, 2012?
Positions of the Parties
Position of the Complainant: The Complainant sought treatment at the Emergency room at a time when no other facilities were available. 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 later with his primary physician. The denial of charges should be upheld.
Opinion of Trustees ROD Case No. 11-0034 Page 2
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 although the Complainant’s symptoms occurred within 48 hours of his visit to the emergency room, the emergency room records do not indicate symptoms that would reasonably require emergency evaluation and/or treatment. The Complainant was not experiencing acute medical symptoms and, therefore, the charges associated with the visit to the emergency room on April 22, 2012, are not 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 not required to
Opinion of Trustees ROD Case No. 11-0034 Page 3
provide benefits for Complainant’s emergency room visit on April 22, 2012.