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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
88-682 – August 3, 1995
Thomas F. Connors, Michael H. Holland, Marty D. Hudson and Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On July 9, 1991, the Employee sought medical evaluation and treatment at a hospital emergency room for symptoms of pain, vomiting, and diarrhea. The record shows that symptoms began three days earlier. The Employee’s physician later stated that he was out of town on vacation at the time. The emergency room physician diagnosed a urinary tract infection and treated and released the patient.
The Employer provided benefits for laboratory and radiology charges, but denied the emergency room charge incurred on July 9, 1991.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on July 9, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred on July 9, 1991 because the Employee’s physician was away on vacation on that date and the Employee’s condition warranted emergency medical treatment.
Opinion of Trustees
ROD Case No. 88-682
Page 2
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on July 9, 1991 because the Employee’s symptoms began three days prior to the emergency room visit and did not worsen within 48 hours of the visit.
Pertinent Provisions Article III. A. (2) (a) of the Employer Benefit Plan states:
(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 provides that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and has advised that the record indicates that the patient’s symptoms began three days prior to the emergency room visit and there is no documentation of the problem getting worse in that time. Because the Employee was not treated for acute medical symptoms within 48 hours of the onset of such symptoms, the Trustees conclude that the Employer is not required to provide benefits for the emergency room charge incurred by the Employee on July 9, 1991. The unavailibility of the Employee’s usual physician does not support, in and of itself, obtaining care at a hospital emergency room. (See ROD 88-532 attached)
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on July 9, 1991.