Complainant: Respondent: ROD Case No:
11-0036 – June 10, 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’s 4 year-old daughter was taken to the local emergency room on September 21, 2012, complaining of constipation and cramping. Emergency room notes indicate that the Complainant’s daughter had not had a bowel movement in four days. The treating physician noted that the child was in no acute distress and appeared comfortable. An examination indicated no abdominal distention or peritoneal signs. Although the patient showed mild tenderness to palpation of the umbilical region, she did not try to stop the physician from pressing deeply into her abdomen. The child was given a pediatric Fleet enema, after which she had a successful bowel movement and was discharged home with instructions on how to treat constipation.
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.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on September 21, 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.
ROD Case No. 11-0036 Page 2
Position of the Respondent: The diagnosis does not indicate an emergency situation. The denial of charges 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(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 did not meet the level of severity and urgency that required emergency services. Therefore, the charge for the visit to the emergency room on September 21, 2012, is not a covered benefit under the terms 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.
The Emergency Medical Physicians’ charges would be a covered benefit under Article III.A.(3)(h) of the Employer Benefit Plan.
ROD Case No. 11-0036 Page 3
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to provide benefits for Complainant’s daughter’s emergency room visit on September 21, 2012. The Employer is responsible for the physicians’ charges of $454.95 associated with the Complainant’s daughter’s visit to the emergency room.