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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-071 – November 8, 1996
Trustees: 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
On August 17, 1994, the Employee began feeling ill while at work. At the end of his shift, he went to his physician but found the office closed. He then went to a hospital emergency room where he was examined and given diagnostic tests.
The Employer provided benefits for the emergency room physician’s charge but has denied benefits for the emergency room facility charge of $77 as well as $60 for diagnostic laboratory tests.
Dispute
Is the Employer required to provide benefits for the emergency room facility charge and diagnostic laboratory tests?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge and diagnostic laboratory tests because the Employee’s physician’s office was closed.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charges because there was no medical emergency and the services could have been provided at a lower level of care.
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) provides benefits for emergency medical treatment that is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.
A Funds’ medical consultant has reviewed the medical documentation submitted in this case, and notes that these records reveal normal vital signs and the only abnormal physical finding being a slightly red throat. The consultant has determined that the patient did not exhibit acute symptoms and that the treatment rendered could have been provided at a lower level of care. Therefore, consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the use of the emergency room. However, the Employer is required to provide benefits for the diagnostic laboratory tests since benefits would have been provided for these at a lower level of care.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room facility charge, but is required to provide benefits for the diagnostic laboratory tests in connection with the Employee’s emergency room visit on August 17, 1994.