______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

Trustees:

In Re

Employee
Employer
88-781 – February 6, 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 health benefits coverage for emergency room charges under the terms of the Employer Benefit Plan.

Background Facts

On Saturday, January 23, 1993 the Employee’s spouse sought evaluation and treatment at a local emergency room complaining of sinus congestion and sore throat beginning the day before. She was evaluated by an emergency room physician who diagnosed her as having pharyngitis and sinusitis. She was given 500 mg. of Rocephin (an antibiotic) intramuscularly, and prescribed Amoxil 500 mg. (an antibiotic), and Entex LA (a decongestant/antihistamine). The emergency room physician instructed the Employee’s spouse to be re-checked if she experienced increased pain, fever or vomiting.

The Employer paid the physician’s fee in connection with the emergency room visit, but denied the hospital charges, stating that care could have been rendered in a physician’s office.

Dispute

Is the Employer required to provide benefits for the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on January 23, 1993?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the emergency room charges on January 23, 1993 because the symptoms occurred within 48 hours of the visit, and since it was a Saturday, her personal physician was unavailable.

Position of the Employer: The Employer is not required to provide benefits for the charges resulting from the Employee’s spouse’s evaluation and treatment in the emergency room of a

Opinion of Trustees Resolution of Dispute Case No. 88-781 Page 2

local hospital because the care could have been rendered in a physician’s office. Additionally, the symptoms were not of an acute nature and did not require emergency treatment.

Pertinent Provisions Article III. A. (2) (a) of the Employer Benefit Plan provides:

(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 an 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 file and notes that the medical record clearly states that the onset of symptoms was acute and occurring within 48 hours of the visit. He further notes that the treating physician felt that the spouse’s symptoms were severe enough that they required an intramuscular injection of Rocephin (an antibiotic) to be given in the hospital prior to discharge, and that the emergency room physician prescribed an oral antibiotic, Amoxil 500 mg., to be taken three times a day. In the opinion of the medical consultant, the emergency room visit of January 23, 1993 was medically appropriate.

Therefore, the Trustees conclude that consistent with the provisions of the Plan, the Employer is required to provide benefits for the emergency room charges incurred as a result of the Employee’s spouse’s evaluation and treatment on January 23, 1993.

Opinion of the Trustees

The Employer is required to provide benefits for the emergency room charges incurred as a result of the Employee’s spouse’s evaluation and treatment on January 23, 1993.