OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
11-0138 – February 27, 2017
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 is a retiree of the Respondent and receives medical benefits coverage from the Respondent secondary to Medicare. The Complainant’s spouse went to the emergency room of her local hospital on October 30, 2015. The patient complained of abdominal pain, nausea, diarrhea and vomiting that began two days earlier. She received multiple laboratory tests, IV medications for symptoms control, and a CT scan of her abdomen. She was discharged with antibiotics for possible enteritis.
The Respondent denied benefits for the emergency room visit as not meeting plan guidelines for emergent care.
Dispute
Is the Respondent required to pay the charges associated with the Complainant’s spouse’s visit to
the emergency room on October 30, 2015?
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.
Opinion of Trustees ROD Case No. 11-0138 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.
Discussion
Article III.A.(2)(a) of the Employer Benefit Plan states that benefits will be provided for emergency medical treatment when the treatment is rendered within 48 hours following the onset of acute medical symptoms. The Funds’ Medical Director has reviewed the emergency room medical records and determined that the visit met both the acuity and the 48-hour timeline required for coverage of emergency services under the Employer Benefit Plan.
Opinion of the Trustees
Pursuant to Article III.A.(2)(a) of the Employer Benefit Plan, the Respondent is required to pay
for the emergency room visit on October 30, 2015, and is responsible for any associated charges that are otherwise covered by the Plan.