OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0035 – 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’s spouse sought medical treatment at the local emergency room on August 24, 2012, complaining of swelling and pain of her right hand. The pain was reported as 9 on a scale of 1 – 10. Emergency room records indicate the hand was swollen, erythematous and warm, and the emergency room physician’s impression was acute cellulitis. Tests confirmed an elevated white blood count consistent with acute cellulitis rather than chronic lymphadema, a condition noted in the patient history notes. Respondent denied the charges associated with the visit to the emergency room, asserting that that the treatment was sought for a chronic condition, not for a medical emergency, and that the beneficiary could have sought treatment from her primary care physician.
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on August 24, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse was experiencing extreme pain that occurred on the day treatment was sought. The charges are a covered benefit.
Position of the Respondent: The Complainant’s spouse did not seek medical attention from her primary care provider and the diagnosis does not indicate an emergency situation. The denial of the claim should be upheld.
Opinion of Trustees ROD Case No. 11-0035 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.
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 symptoms with an onset of 2 – 3 days prior to her admission and a history of chronic lymphadema, the acute symptoms occurred within 48 hours of admission and required emergency treatment. Therefore, the charges associated with the visit to the emergency room on August 24, 2012, 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. The Funds’ Medical Director also notes that there is no requirement in the Employer Benefit Plan that a beneficiary see a personal care physician for acute medical symptoms prior to seeking emergency room medical treatment.
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 August 24, 2012.