OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
16-0010 – November 1, 2018
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 spouse went to the local emergency room on Saturday February 18, 2017, at approximately 8:58 a.m. Her chief complaints were reported as being flu-like symptoms, including a cough, nasal congestion, and a sore throat that started three days earlier. Except for the cough and clear nasal discharge, the results of a physical examination and lab tests were within normal parameters. She was given Tamiflu as a precaution against influenza and discharged. The Respondent denied the emergency room visit charges, stating that the patient’s symptoms were not severe enough to warrant a visit to the emergency room.
Is the Respondent required to pay for the emergency room charges for the Complainant’s spouse’s visit to the emergency room on February 18, 2017?
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the Employer Benefit Plan (“EBP”). The Complainant’s spouse sought appropriate medical care for symptoms that she experienced as she thought they were related to the flu. She went to the ER with her husband, and he was diagnosed with Influenza A during that same emergency room visit.
Position of the Respondent: The emergency room charges are not covered by the EBP because the Complainant’s spouse’s symptoms, as documented in the emergency room records, did not meet the criteria for emergent care.
Opinion of Trustees ROD Case No. 16-0010 Page 2
Pertinent Provisions Article III A.(2)(a) of the 2016 Model EBP 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.
Article III.A.(2)(a) of the 2016 EBP provides benefits for emergency medical treatment in the outpatient department of a hospital when treatment is sought for a medical emergency within 48 hours of the onset of acute medical symptoms. The Funds’ Medical Director has reviewed the medical records in this case and determined that in the absence of severe symptoms, this was not a medical emergency. It is the Funds’ Medical Director’s opinion that the emergency room records show evidence of a minimally ill person, who could have waited to see her primary care physician.
The Complainant’s spouse reported that she had been experiencing flu-like symptoms for 3 days prior to her visiting the emergency room on February 18, 2017. A letter from the Complainant’s spouse, appealing the denial, states that she had been up all night due to severe symptoms prior to presenting at the emergency room. Further, she stated that she was too ill to drive to the nearest urgent care facility or wait two days to see her primary care physician.
Based on the findings of the Funds’ Medical Director that the Complainant’s medical record only showed a “minimally ill person”, the emergency room facility charges for the visit to the emergency room on February 18, 2017, are not a covered benefit under the EBP. The Respondent is therefore only responsible for any associated charges that are otherwise covered by the Plan.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, the Respondent is not required to pay the facility charges for Complainant’s spouse’s emergency room visit on February 18, 2017. However, the Respondent is responsible for any associated charges that are otherwise covered by the Employer Benefit Plan.