OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0043 – August 6, 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 two month-old son was taken to the local emergency room just prior to midnight on June 16, 2012, with complaints of upper respiratory symptoms and possible thrush. Emergency room records indicate that the infant’s pulse and respiratory rates were elevated but within the normal range for infants. A white plaque was present inside the infant’s mouth consistent with a diagnosis of thrush. The infant was treated with an oral antifungal agent and parents were advised to follow-up with the child’s primary care physician in two days.
Respondent denied the charges because the claim was not submitted with an emergent diagnosis.
Is Respondent required to provide benefits for Complainant’s emergency room visit on June 16, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s child was experiencing acute medical symptoms and was taken to the emergency room at a time when no other facility was available for treatment. The charges are a covered benefit under the Employer Benefit Plan.
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.
Opinion of Trustees ROD Case No. 11-0043 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 stated that although the Complainant’s infant son’s symptoms were within the normal range for infants, small infants often present with vague symptoms that may go unrecognized by less-than-careful observers. He further stated that when infants are sick, illnesses can progress rapidly.
The Funds’ Medical Director opined that because the symptoms were acute and had an onset of less than 48 hours prior to the emergency room treatment, they 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.
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 son’s emergency room visit June 16, 2012.