OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
88-853 – August 3, 1995
Thomas F. Connors, Michael H. Holland, Marty D. Hudson and T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room services under the terms of the Employer Benefit Plan.
On August 29, 1993, the Employee went to the emergency room of an area hospital because he began to have dizziness the day before, with pain radiating to his back. The Employee stated he had had indigestion for two weeks. The emergency room record notes a history of hypertension (high blood pressure) for which he was on maintenance medication. The examining physician ordered an electrocardiogram (EKG) which was normal except for tachycardia (rapid heart beat).
The Employer provided benefits for the physician’s charges but denied benefits for the emergency room charges of $134.00, a pharmacy charge of $7.00, medical surgical supplies for $55 and a telemetry charge of $204.
Is the Employer required to provide benefits for the emergency room and related charges incurred by the Employee in his visit on August 29, 1993?
Positions of the Parties
Opinion of Trustees
ROD Case No. 88-853
Position of the Employee: The Employer is required to provide benefits for the emergency room and related charges because the symptoms had became worse within 48 hours of the Employee’s visit to the emergency room.
Position of the Employer: The Employer is not required to provide benefits for the emergency room and related charges because the treatment could have been rendered at a lower level of care.
Article III. A. (2) (a) 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) provides benefits for emergency medical outpatient hospital services when the treatment is rendered within 48 hours of the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and notes that the Employee’s dizziness began the day before treatment and that pain was radiating to the patient’s back. He also noted that the Employee’s symptoms and medical history concerned the attending physician enough for him to order an EKG. For these reasons, the medical consultant is of the opinion that the emergency room visit in this case would be considered medically appropriate.
Therefore, the Trustees conclude that the Employee’s use of the emergency room on August 29, 1993 was medically appropriate, and the Employer is required to provide benefits for the emergency room and related charges incurred.
Opinion of Trustees ROD Case No. 88-853 Page 3
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the emergency room and related charges incurred by the Employee on August 29, 1993.