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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 11-0053
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 spouse sought medical treatment at the local emergency room on July 10, 2012, complaining of a headache, nausea, abdominal pain and dizziness. Symptoms were rated by the patient as mild, and vital signs were normal. Emergency room records indicate that the clinicians had difficulty sorting the importance of the symptoms and establishing a clear timeline for the illness. Medical records do not clearly indicate that symptoms started within 48 hours of the emergency room visit.
Respondent denied the charges, asserting that this was a non-emergency and that treatment was not sought within 48 hours of the initial onset of symptoms.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on
July 10, 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 nor was treatment sought within 48 hours of the onset of symptoms and is not, therefore, a covered benefit. The denial of the claim 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 determined that the medical records do not clearly indicate that the acute symptoms, for which the Complainant’s spouse sought emergency room treatment, started within 48 hours of the emergency room visit.
The Funds’ Medical Director further opined that the symptoms did not meet the acuity requirement for an emergency in addition to commencing within 48 hours of the emergency room visit. Therefore, they are 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.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to provide benefits for Complainant’s emergency room visit on July 10, 2012.