OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0145 – 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 wife went to the local emergency room the evening of June 6, 2016, with complaints of a severe headache and pain in her eyes, back and stomach. The symptoms were reported as starting the previous day, becoming more severe in the hour prior to the emergency room visit. She was treated with Toradol and Morphine and released with a diagnosis of migraine. The Employer denied the emergency room charges as not meeting the criteria for emergency care.
Is the Respondent required to pay for the emergency room visit of the Complainant’s wife on June 6, 2016?
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the provisions of the Employer Benefit Plan. Complainant’s wife’s condition worsened on June 6, 2016, and the severity of her 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. 11-0145 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) 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 Complainant’s wife experienced a headache on June 5, 2016. Her headache worsened on June 6, 2016, and she also began to experience nausea, vomiting and sensitivity to light. She sought treatment at the emergency room on June 6, 2016, due to the increasing severity of the headache and other symptoms. Her diagnosis was a migraine headache.
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 Complainant’s wife’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 June 6, 2016, 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 June 6, 2016.