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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 11-0037
Trustees: 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 daughter sought treatment at the local emergency room on July 19, 2012, complaining of pelvic pain along with a swollen and inflamed left great toe. Emergency room notes indicate that the Complainant’s daughter rated the pelvic pain as moderate and similar to her endometriosis pain of the past. The great toe required a surgical incision and drainage of an infected ingrown toenail, and the patient was discharged on antibiotics and pain medication.
Respondent’s Third Party Administrator denied the charges and Respondent upheld the denial on the basis that the discharge diagnosis indicated the Complainant’s daughter’s medical condition did not warrant emergency medical treatment, and treatment could have been sought from her primary care physician.
Dispute
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on July 19, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter sought treatment at the emergency room for severe abdominal pain and an infected great toe. The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: The diagnosis does not indicate an emergency situation. The Complainant’s daughter had the abdominal pain for two days and could have sought treatment from her primary care physician for the abdominal pain and for the infected toe. 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.
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 noted that Complainant’s daughter received an antibiotic for the infected great toe and pain medications for her abdominal pain. He determined that the Complainant’s daughter experienced the onset of acute medical symptoms relating to her left great toe within 48 hours of her emergency room visit of July 19, 2012, that required urgent evaluation and emergency treatment with a surgical procedure and antibiotics for the infection. Therefore, the charges associated with the visit to the emergency room on July 19, 2012, are 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. Further, 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 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 daughter’s emergency room visit on July 19, 2012.