OPINION OF TRUSTEES
ROD Case No: 11-0052 – November 12, 2013
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.
The Complainant’s spouse sought medical treatment at the local emergency room on September 8, 2012, complaining of a swollen left eye. Triage notes indicate that the swelling in this eye started the same day as the visit to the emergency room. The physician noted erythema and edema of the left eyelid and an injected sclera on the left. The right eye appeared normal. The patient was treated with a steroid injection and discharged on oral prednisone.
Respondent denied the charges, asserting that this was a non-emergency.
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on
September 8, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse was experiencing acute medical symptoms and went to the emergency room on the same day the symptoms occurred. 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 records report an onset three days prior to the emergency room visit. The denial of the claim should be upheld.
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 opined that although the emergency room physician’s notes indicated an onset of three days prior to the emergency room visit, the acute symptoms of the left eye had actually begun the day of the visit to the emergency room. The more detailed triage nurse’s notes have a more complete timeline indicating that three days prior to the emergency room visit, the right eye had been swollen, and on the day of the emergency room visit, it was the left eye that was swollen.
In exercising his clinical judgment, the Funds’ Medical Director discounted the accuracy of the physician notes and relied on the triage nurse’s notes as more accurately describing the history and timeline of symptoms. The Funds’ Medical Director opined that the acuity and onset of the medical symptoms of the left eye meet the requirements to be a covered charge under the terms 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 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 spouse’s emergency room visit on September 8, 2012.