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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-722 – February 16, 1995
Trustees: 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 Sunday, February 7, 1993, the Pensioner sought medical evaluation and treatment at the emergency room of a local medical center for a chronic right ear infection. The Pensioner stated that the pain from the ear infection was causing him to lose sleep.
The emergency room record indicates that the Pensioner was previously seen for the right-sided earache, and was currently under treatment with Entex LA (a decongestant) and Septra DS (an antibiotic), and felt that possibly one of the medications was keeping him awake at night. The emergency room record states that the Pensioner was in no acute distress at the time of the visit. The emergency room physician discontinued the decongestant, Entex LA, and prescribed Cortisporin Otic Suspension (eardrops) in its place. The Pensioner was also directed to follow-up with his personal physician, and to return to the hospital if his symptoms worsened.
The Employer denied benefits for the emergency room charge stating that the Pensioner’s condition had not worsened or become more severe in the 48 hours immediately preceding the emergency room visit. Additionally, the Employer states that at the time of the visit the Pensioner was already under treatment and receiving medications for his earache.
Dispute
Is the Employer required to provide benefits for the Pensioner’s use of the emergency room on February 7, 1992?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the emergency room charge incurred on February 7, 1993 because the Pensioner was in pain and the emergency room was the only medical facility available on a Sunday.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge incurred by the Pensioner on February 7, 1993 because the Pensioner had previously been treated and was currently on medication for his right-sided earache. Additionally, the Pensioner’s condition had not exacerbated in the 48 hours prior to the emergency room 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 benefits for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident. In this case, the Pensioner had already sought treatment for the condition, and was taking an antibiotic (Septra DS) and a decongestant (Entex LA) at the time of the emergency room visit. The emergency room record indicates that the Pensioner thought perhaps one of the medications he was taking was preventing him from sleeping.
A Funds’ medical consultant has reviewed the information in this case and has concluded that there was no evidence of worsening pain or of any new symptoms requiring emergency care and treatment. The consultant states that the emergency physician’s examination of the Pensioner was consistent with the Employees prior history in that there was a continued, but resolving, right-side otitis media. No new physical findings were reported. The consultant advises that the changing of the medications is not indicative of any new symptoms, or of a worsening of the patient’s original condition. For those reasons, the medical consultant is of the opinion that the emergency room visit would not be considered medically appropriate in this case.
Therefore, the Trustees conclude that the Pensioner’s use of the emergency room on Sunday, February 7, 1992, was medically inappropriate, and therefore, not eligible for benefits under Article III.A.(2)(a) of the Employer Benefit Plan.
Opinion of the Trustees
The Employer is not required to provide benefits for the Pensioner’s use of the emergency room on February 7, 1992.