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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 98-027 – November 14, 2001

Trustees: A. Frank Dunham, Michael H. Holland, Marty D. Hudson and Elliot A. Segal.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.

Background Facts

The Complainant’s spouse suffers from severe migraine headaches and has sought frequent emergency room care for treatment. The medications administered to the spouse for the treatment of her migraine headaches included narcotics and non-narcotic prescription analgesics. The Respondent notified the Complainant by letter dated May 26, 2000, that the Respondent would no longer provide coverage for the Complainant’s spouse’s emergency room care for the migraine headaches after April 7, 2000. The Respondent further stated that the spouse “will need to be seen for headache treatment in the doctor’s office.”

The Complainant’s spouse has requested coverage for nine visits to the emergency room for the following dates which have been denied by the Respondent: June 14, 2000; July 4, 2000; August 20, 2000; October 26, 2000; November 2, 2000; November 28, 2000; December 8, 2000, December 30, 2000 and January 13, 2001.

Dispute

Is the Respondent required to provide coverage for the emergency room charges resulting from the treatment of the Complainant’s spouse’s migraine headaches after April 7, 2000?

Positions of the Parties

Position of the Complainant: The Respondent is required to provide coverage for the emergency room charges after April 7, 2000, because the emergency care was medically justified to treat the Complainant’s spouse’s migraine headaches.

Position of the Respondent: The Respondent is not required to provide coverage for the Complainant’s spouse emergency room visits for the treatment of migraine headaches after April 7, 2000 because 1) the emergency room visits were excessive and constituted inappropriate utilization of the services; 2) the visits were not medically necessary as the spouse was engaged in drug seeking behavior. Furthermore, an independent consulting firm hired by the Respondent that reviewed the Complainant’s medical records from 1985 through December 2000, determined that 1) the frequency of the emergency room visits and injections were excessive; 2) the services were unwarranted; and 3) because of possible chemical dependence, the patient’s symptoms should be evaluated further and other treatment options explored.

Pertinent Provisions

The Introduction to Article III states in pertinent part:

Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan . . . . Services which are not reasonable and necessary shall include, but are not limited to the following: . . . procedures which can be performed with equal efficiency at a lower level of care.

Article III A. (2) (a) of the 1998 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

The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care. Under Article III A. (2) (a) of the Employer Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.

The Respondent contends that the Complainant’s spouse utilized the emergency room improperly and that the visits were not medically necessary. To support its position, the Respondent hired an outside medical consultant to review the Complainant’s treatment records from 1985 through December 2000 for medical appropriateness.

In RODs 81-553, 84-703, 88-267 and 88-754, the Trustees concluded that an Employer must provide at least one impartial medical review, such as an independent physician or state peer review panel, when denying claims for medical care deemed inappropriate and/or excessive. In this case, the Respondent obtained an opinion from an independent medical consulting firm regarding the Complainant’s spouse’s treatment. The consulting firm found that the frequency of the emergency room visits and injections was excessive, the services unwarranted, and because of possible chemical dependence, the patients’ symptoms should be evaluated further and other treatment options explored.

A Funds’ medical consultant has reviewed this file, which includes hospital records for each of the emergency room visits in question and the review by the Respondent’s independent medical consultant. The Funds’ medical consultant agreed with the medical assessment provided by the Respondent’s independent consultant who indicated that the Complainant needed to manage her medical problems by specialists in a comprehensive manner and not by episodic visits to the emergency room. The Funds’ consultant further noted that emergency rooms by law and by medical ethics have to evaluate and treat a patient whenever they present themselves. An alternative for a health plan is to notify the patient of non-coverage for his or her emergency room visits involving a specific problem. This was the approach taken by the Respondent when on May 26, 2000, the Respondent advised the Complainant that the emergency room visit on April 7, 2000, would be the last visit paid by the Respondent. In the consultant’s opinion, the nine visits in question do not meet the medical necessity requirements as outlined in Article III of the Employer Benefit Plan. Therefore, the Trustees conclude that the Respondent is not required to provide benefits for the emergency room charges resulting from the Complainant’s spouse’s visits on June 14, 2000; July 4, 2000; August 20, 2000; October 26, 2000; November 2, 2000; November 28, 2000; December 8, 2000; December 30, 2000 and January 13, 2001.

Opinion of the Trustees

The Respondent is not required to provide benefits for the emergency room charges resulting from the Complainant’s spouse’s nine emergency room visits from June 14, 2000 though January 13, 2001.