OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0105 – May 25, 2016
Michael H. Holland, Marty D. Hudson, 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 December 10, 2012, the Complainant’s dependent daughter was brought to the Emergency Department (“ED”) of a hospital. She had twice been to urgent care over the previous 3-4 weeks and had been treated for streptococcal pharyngitis, a urinary tract infection, and a yeast infection. For the week prior to the ED visit, she had experienced backache, chills, cough, runny nose, and a sore throat. She was discharged with a diagnosis of influenza, right otitis media, and a urinary tract infection.
On February 19, 2013, the patient was again brought to the hospital ED. She presented with a fever and had been exposed to bacterial meningitis. Complainant’s daughter visited urgent care 2 days prior to the ED visit, and, after her fever persisted, urgent care referred her to the ED. A neurologic examination for the signs of bacterial meningitis was negative, and she was discharged with a diagnosis of viral upper respiratory infection.
In December 2012 and March 2013, Respondent denied the Complainant’s claims for payment for the ED visits. Consequently, the Complainant’s representative attempted to file an appeal on February 6, 2014, but the Respondent’s third party administrator denied the appeal because more than 180 days had passed since the initial adverse benefit determination.
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visits on December 10, 2012, and February 19, 2013?
Opinion of Trustees ROD Case No. 11-0105 Page 2
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.
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 patient had been ill for more than a week without an indication that new acute symptoms developed within 48 hours prior to the ED visit on December 10, 2012. Therefore, the Respondent should not be responsible for the emergency room facility expenses associated with the December 10, 2012, ED visit. Nevertheless, given that the Funds’ Medical Director concluded that the laboratory services would be covered as medically necessary in non-emergency settings, the laboratory services associated with the December 10, 2012, ED visit are the responsibility of the Respondent.
With respect to the February 19, 2013, ED visit, the Funds’ Medical Director determined that treatment was rendered within 48 hours after the onset of acute medical symptoms and that, therefore, the Respondent is responsible for these services. 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 Trustees ROD Case No. 11-0105 Page 3
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 emergency room facility expenses for the February 19, 2013, visit but not the December 10, 2012, visit. The Respondent is also required to provide benefits for the laboratory services associated with the December 10, 2012, ED visit.