OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
93-094 – March 17, 2000
A. Frank Dunham, Michael H. Holland, Donald E. Pierce, Jr. and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute under the terms of the 1993 Employer Benefit Plan concerning the provision of benefits for emergency room care.
The Employee’s spouse had a hysterectomy on March 23, 1994 that was complicated by excessive bleeding the day after surgery and for which she received two units of blood. Following discharge, she had painful urination and was diagnosed with a urinary tract infection (UTI). In the evening of April 8, 1994, she began experiencing severe flank pain unlike the pain she incurred with the UTI. Her attending physician advised her to go to the emergency room because it was likely that she had a kidney stone.
After taking her history and conducting an examination, the emergency room physician expressed concern that she also might have a pelvic abscess and suggested various diagnostic procedures. Subsequently, the Employee’s spouse urinated and the pain ceased. It was presumed that she had passed a kidney stone which would explain both the presence of severe flank pain and its sudden disappearance.
The Employer has denied benefits for the use of the emergency room, stating that the Employee’s spouse’s symptoms were not life threatening and treatment in a clinic or office would have been more appropriate.
Is the Employer required to provide benefits for the Employee’s spouse’s emergency room charges?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charges because the treatment was medically necessary.
Opinion of Trustees ROD Case No. 93-094 Page 2
Position of the Employer: The Employer is not required to provide benefits for the emergency room charges because the Employee’s spouse’s symptoms were not life threatening and she could have been treated at a lower level of care.
Pertinent Provisions Article III A. (2) (a) of the 1993 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.
Q&A 81-10 states, in pertinent part:
Subject: Definition of Emergency Treatment Benefit References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (2) (a) and A (3) (i)
Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
1. Would emergency treatment for conditions such as the following be covered under this provision:
- – acute pain attributed to gout?
- – heart attack, severe chest pain, or congestive failure experienced by a
patient with (chronic) heart disease?
- – intracranial bleeding or stroke experienced by a patient with hypertension?
1. Yes, because the symptoms are acute and require emergency treatment,
Opinion of Trustees ROD Case No. 93-094 Page 3
even though the underlying illness causing the symptoms may be chronic. Discussion
Article III A. (2) (a) provides emergency room benefits for treatment received within 48 hours of the onset of acute medical symptoms. Q&A 81-10 explains that the acuteness of symptoms may require emergency treatment even though the underlying cause may be chronic; i.e., not life threatening.
A Funds’ medical consultant has reviewed the documentation submitted in this case and notes the physician’s concern about potentially serious medical problems. He is of the opinion that the patient’s condition, and the timing involved, clearly warranted emergency evaluation and treatment. Therefore, consistent with the provisions of the 1993 Employer Benefit Plan, the Employer is required to provide benefits for the emergency room treatment for the Employee’s spouse on April 8, 1994.
Opinion of the Trustees
Consistent with the provisions of the 1993 Employer Benefit Plan, the Employer is required to provide benefits for the emergency room treatment for the Employee’s spouse on April 8, 1994.