In Re

Complainant: Pensioner
Respondent: Employer
ROD Case No: 11-0128 – May 25, 2016

Trustees: 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.

Background Facts
The Complainant’s spouse sought treatment for a sore throat at the local emergency room on Friday, August 29, 2014, at 1:30 a.m. The emergency room records indicate that the patient’s symptoms of a cough with chest discomfort, sore throat, hoarseness and nasal congestion began about three days prior to the visit, and were initially mild and non-acute. The patient also reported that her symptoms were worse that night and that she felt like she was going to pass out.

Nebulizer treatment was performed after triage and before a doctor’s evaluation, and residual wheezes were present following the treatment. Throat cultures were negative for strep and a chest x-ray was found to be normal. The patient was discharged with a primary diagnosis of acute pharyngitis.

The Respondent denied the ER charges, stating that the patient’s symptoms were present three days prior to the emergency room visit, the diagnosis was not medically necessary, and the visit did not meet the criteria for emergency treatment.

Is the Respondent responsible for the emergency room facility services, tests, x-rays, and associated physician charges on August 29, 2014?

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 did not submit a response to the complaint.

Pertinent Provisions
Article III A (2)(a) of the Employer Benefit Plan states:
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 opined that the patient’s symptoms met the criteria for emergency treatment. Although the symptoms started about three days before the emergency room visit and were initially mild, the treatment rendered in the emergency room indicates a level of acuity consistent with a medical emergency.

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, charges for tests and x-rays and any other ancillary charges associated with the August 29, 2014, emergency room visit.