OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0139- May 31, 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.
The Complainant is a retiree of the Respondent and receives medical benefits coverage from the Respondent secondary to Medicare. The Complainant’s spouse sought medical treatment at the local emergency room on Friday, February 5, 2016, at approximately 8:35 a.m., complaining of severe back pain. The back pain started the previous day. She was about sixty miles from home, caring for her disabled mother. She went to the closest care facility, the local emergency room, which was just a few blocks away from her mother’s home, because her mother was not to be left unattended due to her condition.
The Complainant’s spouse was diagnosed with low back strain and received injections of Decadron and Toradol. She was then discharged with prescriptions for Robaxin and Medrol. The Respondent denied benefits for the emergency room visit as not meeting plan guidelines for emergent care. Respondent paid the associated physician charges.
Is the Respondent required to pay the charges associated with the visit of Complainant’s spouse to the emergency room on February 5, 2016?
Positions of the Parties
Position of the Complainant: The Complainant’s spouse was experiencing severe symptoms and went to the emergency room within 48 hours of symptom onset. The charges are a covered benefit under the Employer Benefit Plan.
Opinion of Trustees ROD Case No. 11-0139 Page 2
Position of the Respondent: The symptoms of Complainant’s spouse were not a true emergency and could have been handled at a lower level of care.
Pertinent Provisions Article III A.(2)(a) of the Employer Benefit Plan states:
ARTICLE III BENEFITS A. Health Benefits
(2) Outpatient Hospital Benefits
(a) 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 the treatment is rendered within 48 hours following the onset of acute medical symptoms. The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary and which are given at the appropriate level of care. The Introduction also states that services that are not reasonable and necessary shall include procedures which can be performed with equal efficacy at a lower level of care.
The Funds’ Medical Director has reviewed the emergency room medical records and determined that the patient’s acute medical symptoms met the requirements for timeliness and severity and although the care received at the emergency room could have been provided in a lower level of care setting, that the beneficiary was not in her home community should be considered. Patient knowledge of lower-care treatment facilities than the emergency room is the assumption for denials when a lower level of care facility is an option. The beneficiary was away from home and unfamiliar with convenient less-intense services in the area when she developed acute back pain. Additionally, the injections she received at the emergency room may not have been available in a less-intense setting. Therefore, in consideration of the overall context, the charges associated with the visit to the emergency room on February 5, 2016, are a covered benefit under the Employer Benefit Plan. The Employer is, therefore, responsible for all the charges associated with the beneficiary’s emergency room visit.
Opinion of Trustees ROD Case No. 11-0139 Page 3
Opinion of the Trustees
Pursuant to the Article III.A.(2)(a) of the Employer Benefit Plan, the Respondent is required to pay for the all charges for Complainant’s spouse’s emergency room visit on February 5, 2016.