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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 11-0107 – June 9, 2015
Trustees: Michael H. Holland, Marty D. Hudson, Michael O. McKown, and
Joseph R. Reschini
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
On February 17, 2013, the Complainant’s spouse visited the emergency department (“ED”) of a hospital and complained of right leg and back pain that had persisted for one month. There had been no fall or injury leading to the onset of the pain, but she felt a “knot” in her thigh and claimed she had hit her knee on a car door. She saw her primary care physician once and a chiropractor three times for this condition and then visited the ED after the pain had worsened in the week prior to the ED visit. Complainant’s spouse claims she was concerned there was a possible blood clot, but a blood clot was not mentioned in the records as a concern of the patient or clinicians. X-rays were performed on the right hip and knee, but there were no acute findings. The ED discharge diagnosis was pain of the right hip and knee.
In correspondence to Complainant’s representative, Respondent supported the denial of payment for the ED visit and stated that the appeal was upheld due to a non-emergent diagnosis.
Dispute
Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on February 17, 2013?
Positions of the Parties
Position of the Complainant: The charges are a covered benefit under the Employer Benefit Plan.
Position of the Respondent: No position was submitted by the Respondent.
Pertinent Provisions
Article III.A(2)(a) of the Employer Benefit Plan states:
ARTICLE III BENEFITS
A. Health Benefits
(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 symptoms were active for at least a week prior to the ED visit and that there was no history of acute progression within 48 hours of the visit. Therefore, the Funds’ Medical Director concluded that the Respondent should not be responsible for the emergency room facility expenses.
Nevertheless, the Funds’ Medical Director determined that the physician and ancillary services would meet medical necessity criteria when provided in a non-emergency setting and, thus, should be the responsibility of the Respondent.
Respondent’s consideration of a non-emergent diagnosis 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 the emergency room facility expenses, but is required to provide benefits for the physician and ancillary services.