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OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
11-0029 – 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 sought medical treatment at the local emergency room on March 20, 2012, for right knee pain, that started the night before, and chronic back and hip pain. The knee, back and hip pain escalated to the point that he was unable to sleep. Complainant returned to the emergency room on March 25, 2012, barely able to walk, complaining of pain and warmth in his right knee. Respondent’s Third Party Administrator denied the charges for each emergency room visit and Respondent upheld each denial on the basis that the discharge diagnoses indicated that the Complainant’s medical condition did not warrant emergency medical treatment on either occasion according to the Respondent’s Plan.
Dispute
Is Respondent required to provide benefits for Complainant’s emergency room visits on March 20, 2012, and March 25, 2012?
Positions of the Parties
Position of the Complainant: The Complainant experienced acute symptoms and utilized the emergency room within 24 hours of the onset of those symptoms. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Position of the Respondent: The March 20 and March 25, 2012 discharge diagnoses do not indicate that Complainant was treated in the emergency room on either date for an emergency medical condition and therefore he is not entitled to coverage under the Employer Benefit Plan.
Opinion of Trustees ROD Case No. 11-0029 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 the onset of Complainant’s acute medical symptoms on March 20, 2012, occurred less than 48 hours prior to his receipt of emergency room treatment. The Funds’ Medical Director stated that there was no medical documentation that Complainant experienced new acute medical symptoms within 48 hours of the Complainant’s second emergency room visit on March 25, 2012.
Therefore, because the acute medical symptoms had an onset of less than 48 hours prior to the time Complainant received emergency room treatment on March 20, 2012, the charges associated with the emergency room visit are a covered benefit under the terms of the Employer Benefit Plan. However, because there is no medical documentation that Complainant experienced new acute medical symptoms occurring within 48 hours of his receipt of emergency room treatment on March 25, 2012, the charges associated with the March 25, 2012 visit are not a covered benefit under the terms of the Employer Benefit Plan.
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, Respondent is required to provide benefits for Complainant’s emergency room visit on March 20, 2012. The Respondent is not required to provide benefits for Complainant’s emergency room visit on March 25, 2012.