Complainant: Respondent: ROD Case No:
11-0071 – May 20, 2015
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.
The Complainant sought medical treatment at the local emergency room on November 27, 2012, complaining of a headache and chills, and memory loss of two-week duration. Emergency room notes indicate that the Complainant has a history of headaches that now include throbbing in his left eyelid. He also complained of left-sided neck pain that radiated to his arm and fingers when he leaned left. Notes from the attending physician, emergency room nurse and a resident physician, all of whom examined the Complainant, indicated that symptoms began at least three days prior to the emergency room visit with no indication of progression of symptoms. Respondent’s Third Party Administrator denied the charges citing onset of symptoms more than 48 hours prior to the emergency room visit.
Is Respondent required to provide benefits for Complainant’s emergency room visit on November 27, 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.
ROD Case No. 11-0071 Page 2
Position of the Respondent: Claimant stated that memory loss was the primary reason for seeking treatment. The onset of this complaint was greater than 48 hours. The charges should be denied for exceeding the 48-hour requirement to seek treatment.
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.(3)(h) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care (h) Home, Clinic, and Office Visits
Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, if provided by a physician.
Article III.A.(3)(j) of the Employer Benefit Plan states:
(3) Physicians’ Services and Other Primary Care (j) Laboratory Tests and X-rays
Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, illness or injury.
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 onset of acute medical symptoms occurred more than 48 hours prior to the emergency room visit.
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Therefore, the charge for the visit to the emergency room on November 27, 2012, is not a covered benefit under the terms of the Employer Benefit Plan. However, the associated charges of $2,151.14 for lab work, tests, and physician charges are covered under the terms of the Plan.
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 November 27, 2012. The Employer is responsible for the associated charges of $2,151.14 for physician charges, lab work and other tests ordered on November 27, 2012, during the emergency room visit.