OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
93-095 – July 22, 1998
Trustees: Michael H. Holland, Michael O. McKown, 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.
In the afternoon of May 27, 1997, the Employee went to the emergency room because he had not been feeling well for about one week. He stated that he had weakness, fatigue and was depressed. Routine diagnostic studies were performed, including HIV studies requested by the Employee. The results of the studies were within normal limits. The Employee was prescribed medication and discharged with instructions to see his local medical doctor if he did not improve.
The Employer denied benefits, stating that emergency room care was not medically necessary.
Is the Employer required to provide benefits for the Employee’s emergency room visit?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room visit because the Employee was ill and had to see a doctor.
Opinion of Trustees
ROD Case No. 93-095
Position of the Employer: The Employer is not required to provide benefits for the emergency room visit because the Employee’s condition did not require emergency room care.
Article III (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.
Article III A. (2) (a) provides benefits for emergency medical treatment rendered within 48 hours following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the documentation submitted with this case and has concluded that there were no acute complaints or medical symptoms; also, the expressed symptoms had been present for one week. Since the symptoms were not acute and the treatment was not sought within 48 hours, the Employer is not required to provide benefits for the Employee’s emergency room care on May 27, 1997.
Opinion of the Trustees
Consistent with the provisions of the 1993 Employer Benefit Plan, the Employer is not required to provide benefits for the Employee’s emergency room care on May 27, 1997.