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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 11-0057
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 August 11, 2012, complaining of pain and swelling of the left great toe that had migrated to her foot and knee. Weight-bearing, walking and palpation exacerbated the pain, which was moderate (5 out of 10) at the time of the emergency room visit. Emergency room records indicate that the symptoms started two days prior to the emergency room visit, and a statement from the patient, included in the submission, indicated that she had been referred to the emergency room by the local urgent care facility to rule out a possible blood clot.
Respondent denied the charges, asserting that this was a non-emergency.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on
August 11, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse had acute medical symptoms and went to the emergency room as directed by the local urgent care facility. The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: The claim was not submitted with an emergency diagnosis. 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 examination performed in the emergency room was classic for acute gout, which can cause symptoms involving the foot and lower leg. The Medical Director opined that the acuity of the symptoms and the timeliness of the visit to the emergency room meet the requirements for coverage under 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 required to provide benefits for Complainant’s spouse’s emergency room visit on August 11, 2012.