____________________________________________________________________________
OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
11-0019 – March 27, 2013
Michael H. Holland, Daniel L. Fassio, and Marty D. Hudson
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 twenty-three year-old daughter went to the local emergency room on February 26, 2012, with flu like complaints of a headache, stuffy nose, generalized weakness and nausea. Emergency room medical notes indicate the Complainant’s daughter’s temperature was 97.8 degrees, with no new symptoms reported. The symptoms present were documented as mild with a gradual onset. Respondent’s Third Party Administrator denied the charges and Respondent upheld the denial on the basis that the discharge diagnosis indicated that the Complainant’s daughter’s medical condition did not warrant emergency medical treatment according to a PPO agreement that does not cover non-emergency diagnosis codes.
Dispute
Is Respondent required to provide benefits for Complainant’s daughter’s emergency room visit on February 26, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter was ill and utilized the emergency room at a time when no alternative treatment facility was available. The charges are a covered benefit under the Plan.
Position of the Respondent: The claim was not submitted with an emergency diagnosis and therefore the denial of the claim should be upheld.
Opinion of Trustees ROD Case No. 11-0019 Page 2
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) of the Employer Benefit Plan provides benefits for emergency medical treatment if the emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms. The Funds’ Medical Director reviewed the file, including the emergency room records, and determined that there was no documentation of the onset of acute medical symptoms prior to Complainant’s daughter’s receipt of emergency room treatment. Therefore, the charges associated with the emergency room visit are not a covered benefit under the terms of the Employer Benefit Plan.
The Funds’ Medical Director notes that Respondent’s consideration of non-emergent diagnosis discharge codes as the basis for determining the medical necessity or appropriateness of coverage of emergency medical treatment under the Employer Benefit Plan is not consistent with the terms, provisions, and requirements of the Employer Benefit Plan.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is not required to provide benefits for Complainant’s daughter’s emergency room visit on February 26, 2012.