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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 11-0100 – 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.
Background Facts
On March 8, 2013, the Complainant’s spouse sought treatment at the emergency department of the local hospital. The chief complaint was eye redness that started earlier the same day. She alleged that her primary care physician had retired and that she had not been able to secure an appointment with another physician. Complainant’s spouse was diagnosed with a skin rash, sent home with a topical antibacterial cream and advised to schedule a follow-up dermatology appointment.
The Complainant’s spouse visited the emergency department of a hospital on July 15, 2013, after a referral from an urgent care center. Her chief complaint was a right facial droop – with an onset of the same day as the emergency room visit – that she feared was a stroke. The Complainant’s spouse reported a previous insect bite and a skin rash and was diagnosed with Bell’s Palsy presumptively caused by Lyme disease. Later testing confirmed that she had contracted Lyme disease.
Respondent appears to have denied payment for both emergency room visits based on the discharge diagnosis.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visits on March 8, 2013, and July 15, 2013?
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.
Pertinent Provisions
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.
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 emergency room visits on March 8, 2013, and July 15, 2013, met the timeliness and acuity requirements of the Employer Benefit Plan and that, therefore, the Respondent should be responsible for the emergency room expenses.
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 the March 8, 2013, and July 15, 2013, emergency room visits.