OPINION OF TRUSTEES
ROD Case No: 11-0097 – June 9, 2015
Trustees: Michael H. Holland, Marty D. Hudson, Michael O. McKown, and
Joseph R. Reschini
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
On October 12, 2012, the Complainant’s dependent daughter was brought to the Emergency Department (“ED”) of a hospital. Her mother indicated that she had been suffering from a sore throat and an off-and-on fever for 24 hours prior to visiting the ED. She was diagnosed with streptococcal tonsillitis and treated with an antibiotic and acetaminophen.
The Respondent’s third party administrator denied the Complainant’s claim on October 31, 2012. Consequently, the Complainant’s representative filed an appeal request, but the Respondent’s third party administrator refused to review the appeal because it received the appeal request on April 28, 2014, which was more than 180 days after the date of the initial adverse benefit determination.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on October 12, 2012?
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: No position was submitted by the Respondent.
Article III.A(2)(a) of the Employer Benefit Plan states:
ARTICLE III BENEFITS
A. Health Benefits
(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, while the symptoms began less than 48 hours prior to the ED visit, the patient did not appear to meet the acuity requirements of the Employer Benefit Plan and, therefore, that the ED visit did not meet the criteria for coverage as an emergency service under the Employer Benefit Plan. Nevertheless, the Medical Director concluded that the physician and laboratory services would have been covered under the Employer Benefit Plan in non-emergency settings as medically necessary for this illness.
Although the Employer refused to review the appeal because it was not received within 180 days of the original denial, there is no requirement in the Employer Benefit Plan that an appeal must be filed within any time frame.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to provide benefits for the emergency room facility expenses, but is required to provide benefits for the physician and laboratory services.