OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0118 – December 14, 2015
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.
The Complainant and his spouse sought medical care for their two year-old son at the local emergency room on Wednesday, December 26, 2012, at 3:33 a.m. The parents reported that the child awoke from sleep and would not stop crying. Emergency room records noted that the child had been treated with antibiotics for an upper respiratory infection the previous week at a local urgent care center and that the child’s cough had become worse “today” before the emergency room visit. On examination, the child’s vital signs were normal, he was tearful and fussy, his oral cavity and throat were normal, and his tympanic membranes (ear drums) were red and bulging bilaterally. The emergency room physician diagnosed the child as having bilateral otitis media. Although the upper respiratory infection was treated the previous week, it had evolved into a second illness, bilateral otitis media, which caused new and acute symptoms that occurred within 24 hours of the emergency room visit.
The Respondent denied all charges as non-covered services. An appeal was file with the Respondent’s Third Party Administrator, but no communications have been submitted as to the appeal’s status.
Is the Respondent responsible for the emergency room facility services and the associated physician charges for the December 26, 2012, visit?
Opinion of Trustees ROD Case No. 11-0118 Page 2
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the Employer Benefit Plan. The services rendered to treat the patient’s illness were medically necessary and meet the criteria for coverage for emergency services under the Plan.
Position of the Respondent: The Respondent did not submit a response to the complaint.
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 states that benefits will be provided for emergency medical treatment when such treatment is provided within 48 hours following the onset of acute medical symptoms. The child’s initial illness was an upper respiratory infection that started a week before the emergency room visit. Based on the emergency room records, this illness was treated, but it had evolved into a second illness, bilateral otitis media. The bilateral otitis media caused new and acute symptoms that occurred within 24 hours of the emergency room visit. The Funds’ Medical Director has reviewed the medical records submitted and opined that the ear infections (bilateral otitis media) meet the criteria for emergency treatment, since the ear infections can be considered separate from the initial upper respiratory infection and the child’s illness became acute less than 48 hours before treatment in the emergency room. Thus, the employer should be responsible for the emergency room facility charges, the physician charges and any other ancillary charges associated with the emergency room visit of December 26, 2012.
Opinion of Trustees ROD Case No. 11-0118 Page 3
Opinion of the Trustees
Pursuant to Article III.A.(2)(a) of the Employer Benefit Plan, the Respondent is required to pay the emergency room facility charges, the physician charges and any other ancillary charges associated with the December 26, 2012, emergency room visit.