OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0058 – November 20, 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 sought medical treatment at the local emergency room on July 6, 2012, complaining of head and neck pain of two-day duration with gradual onset and intermittent progression. Emergency room notes indicate that the Complainant rated the pain as 7 out of 10. The emergency room physician ordered a CT scan of the head and neck, the results of which were negative. Respondent’s Third Party Administrator denied the charges citing a lack of documentation, and Respondent upheld the denial on the basis that the Complainant’s medical condition was not an emergency.
Is Respondent required to provide benefits for Complainant’s emergency room visit on July 6, 2012?
Positions of the Parties
Position of the Complainant: The Complainant sought treatment at the emergency room for severe head and neck pain. The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: The diagnosis does not indicate an emergency situation. The denial of charges should be upheld.
Opinion of Trustees ROD Case No. 11-0058 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 determined that although the Complainant’s early symptoms had an onset of slightly more than 48 hours before his visit to the emergency room, the record suggests that the symptoms progressed over time to become acute within 48 hours of the emergency room visit. He also noted that the fact that the emergency room physician ordered a CT study of the Complainant’s head and neck reinforces the acute nature of the Complainant’s symptoms. Therefore, the charges associated with the visit to the emergency room on July 6, 2012, are 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 required to provide benefits for Complainant’s emergency room visit on July 6, 2012.