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OPINION
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 11-0064
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 August 4, 2012, complaining of chronic back pain (rated at 5 on a pain scale of 0 – 10). The emergency room physician’s notes indicate an onset of symptoms three days earlier. The physical examination was normal except for tenderness in the central mid-lower back area. Neither the triage nurse nor the emergency room physician noted any progression of symptoms within 48 hours prior to the emergency room visit.
Respondent denied the charges, asserting that his medical condition was a non-emergency.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on
August 4, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse was experiencing acute medical symptoms immediately prior to 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. 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 symptoms for which the Complainant’s spouse sought emergency room treatment had an onset of greater than 48 hours with no indication of any progression during that time. The Medical Director opined that the emergency room charges would not, therefore, be a covered benefit under the terms and provisions 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
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 August 4, 2012. The Employer is responsible for any associated charges that are otherwise covered by the Plan.