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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
Employee
Employer
93-012 – July 1, 1996
In Re
Thomas F. Connors, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
The Employee sustained a cut on his arm. On April 29, 1994, a Friday evening, after noticing a red line going up his arm that he thought might be blood poisoning, the Employee sought treatment at a hospital emergency room. Although the Employee was in no acute distress at the time, the physician diagnosed his condition as cellulitis (infection) and ascending lymphangitis that required immediate antibiotic intervention. The medical file noted that the Employee is allergic to penicillin.
The Employer has denied benefits, saying that the case was not considered an emergency. Dispute
Is the Employer required to provide benefits for the Employee’s emergency room visit on April 29, 1994?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room visit because the treatment was due to an injury and was given within 24 hours of the onset of acute symptoms.
Position of the Employer: The Employer is not required to provide benefits because there was no emergency.
Pertinent Provisions
Opinion of Trustees ROD Case No. 93-012 Page 2
Article III A. (2) (a) 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 outpatient hospital care when treatment is required for an injury or as the result of an accident provided the care is rendered within 48 hours following the onset of acute symptoms or the occurrence of the accident. The Employee went to the hospital emergency room immediately upon noticing the red line on his arm. The emergency room physician diagnosed the case as cellulitis, a form of infection that requires immediate treatment to prevent spreading or further complications. A Funds’ medical consultant has reviewed the documentation in this case and has concluded that the Employee’s condition required immediate evaluation and treatment and that care should not have been delayed for two or three days. Therefore, the Employer is required to provide benefits for the Employee’s emergency room visit on April 29, 1994.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the Employee’s emergency medical treatment on April 29, 1994.