OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0126 – July 27, 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.
The Complainant is a pensioner receiving health benefits coverage from the Respondent. The Complainant’s spouse sought treatment at the local emergency room on Thursday October 11, 2012, at 1:20 p.m. for pain in her face, neck and ear. The patient has a long history of chronic facial, neck and ear pain and was under the care of a pain specialist. Her examination was essentially normal and she was discharged with a pain medication and instructions to follow-up with her primary care physician.
The Respondent initially denied all of the emergency room charges. Subsequent to the filing of a request for resolution of dispute the Respondent paid the ancillary charges for the emergency room physician and $12.80 of the pharmacy charges.
Is the Respondent required to provide benefits for the Complainant’s spouse’s emergency room visit on October 11, 2012?
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 met the criteria for coverage for emergency services under the Plan.
Position of the Respondent: The Respondent’s position is that the Complainant’s spouse did not seek treatment at the emergency room within 48 hours of the onset of acute symptoms and the severity and urgency of her condition did not warrant emergency room care. Also, take home medications are excluded under the Plan.
Opinion of Trustees ROD Case No. 11-0126 Page 2
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(4)(b) of the Employer Benefit Plan states:
ARTICLE III BENEFITS A. Health Benefits
(4) Prescription Drugs
(b) Benefits Excluded
Benefits shall not be provided under subsection (4)(a) for the following:
1. Medications dispensed in a hospital (including take-home drugs), skilled nursing facility or physician’s office. (See Article III A (1)(a) and (5)(a) for benefits provided for drugs and medications during inpatient confinement in a hospital skilled nursing facility.)
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 Funds’ Medical Director has reviewed the medical records submitted and opined that the patient’s symptoms started four to six days before the emergency room visit. Further, the records did not indicate that the symptoms progressed within 48 hours preceding the emergency room visit so as to qualify as new acute medical symptoms.
Article III.A.(4)(b)1 does not require payment for medications dispensed in a hospital for the patient to take home. The records show that upon discharge the patient received medication for pain.
Opinion of Trustees ROD Case No. 11-0126 Page 3
Based on the foregoing, the emergency room facility charges for the visit by the Complainant’s spouse on October 11, 2012, and the charge for medication that she took home (in the amount of $61.00) do not satisfy the criteria necessary to be covered under the Plan. The Complainant’s spouse did not meet the 48 hour requirement for emergency services and take home medication is specifically excluded under the Plan. Thus, the Employer should not be responsible for the emergency room facility charges or the take home medication.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) and Article III.A(4)(b) of the Employer Benefit Plan, the Respondent is not required to pay for the Complainant’s spouse’s emergency room facility charge for the October 11, 2012, emergency room visit and is not required to pay for the medications that were taken home.