Complainant: Respondent: ROD Case No:
OPINION OF TRUSTEES
11-0141 – June 12, 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’s son was treated with antibiotics by his primary physician for an upper respiratory condition on October 14, 2015. Two days later, the Complainant’s son developed a severe headache and a fever and went to his local emergency room. He was treated and released with a diagnosis of acute sinusitis. The Employer paid the physician portion of the bill but denied the charges for the emergency room visit on the basis that the diagnosis did not meet the criteria for emergency treatment. The denial was upheld on appeal.
Is the Respondent required to pay for the emergency room visit of the Complainant’s son on October 16, 2015?
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the provisions of the Employer Benefit Plan. The Complainant’s son’s condition worsened on October 16, 2015, and the severity of his symptoms warranted treatment at the emergency room.
Position of the Respondent: The Respondent did not submit a response to the complaint.
Opinion of Trustees ROD Case No. 11-0141 Page 2
Pertinent Provisions Article III A.(2)(a) of the Employer Benefit Plan states:
ARTICLE Ill 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 child’s initial illness was an upper respiratory infection. Based on the emergency room records, the child had developed a severe headache and fever on the day of the emergency room visit. His diagnosis was acute frontal sinusitis. The child’s primary care physician later wrote that the emergency room visit was important to rule out meningitis.
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 for coverage of emergency services by the Employer Benefit Plan. The child’s symptoms became acute less than 48 hours before treatment in the emergency room. Therefore, the charges associated with the visit to the emergency room on October 16, 2015, are a covered benefit 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 the emergency room facility charges, the physician charges and any other ancillary charges associated with the emergency room visit on October 16, 2015.