____________________________________________________________________________
OPINION ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
11-0045 – 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.
Background Facts
The Complainant’s spouse sought medical treatment at the local emergency room on June 20, 2012, complaining of right heel pain and swelling of the right ankle. The emergency room physician’s notes indicate an onset of symptoms three weeks prior to the emergency room visit. There is no reference in the clinical notes of any acute symptoms developing within 48 hours of the emergency room visit.
Respondent denied the charges, asserting that treatment was not sought within 48 hours of the onset of symptoms and the discharge diagnosis indicated that her medical condition was a non- emergency.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on June 20, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse was experiencing acute medical symptoms that developed the same day as admission to the emergency room. 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 the emergency room visit did not occur within 48 hours of symptoms developing. The denial of the claim should be upheld.
Opinion
ROD Case No. 11-0045 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.(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.(3)(j) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care (j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
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 determined that the acute symptoms for which the Complainant’s spouse sought emergency room treatment had an onset of more than 48 hours. The Medical Director opined that the emergency room charges would not be a covered benefit under the terms and provisions of the Employer Benefit Plan.
The Funds’ Medical Director also noted that Respondent’s consideration of non-emergent diagnosis discharge codes as the basis for determining the medical necessity or appropriateness
Opinion
ROD Case No. 11-0045 Page 3
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 X-rays, physicians’ charges and radiological imaging charges are a covered benefit under the Employer Benefit Plan.
Opinion
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to
provide benefits for Complainant’s spouse’s emergency room visit on June 20, 2012. The Employer is responsible for the emergency physicians, X-rays, and radiological imaging associates’ charges totaling $878.40.