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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-680 – June 2, 1993
Board of Trustees: Michael H. Holland, Chairman; Thomas F. Connors, Trustee; Marty D. Hudson, Trustee; Robert T. Wallace, Trustee.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency medical treatment under the terms of the Employer Benefit Plan.
Background Facts
On May 11, 1992 at 3:43 p.m. the Employee sought treatment at a local hospital for an earache. The emergency room record reflects that the Employee’s symptoms had been present for two days. The Employee denied any recent congestion or upper respiratory infection. The emergency room record indicates that the discharge diagnosis was left otitis externa and left otitis media (external and middle ear infection). The record does not contain any information regarding treatment or medications which may have been prescribed.
The Employee states that he sought treatment at the emergency room because his symptoms had become “unbearable”. He also stated that the emergency room was the only place where he could receive treatment at the time.
The Employer notes that benefits were provided for the physician’s charge
but denied benefits for the use of the emergency room.
Dispute
Is the Employer required to provide benefits for charges resulting from the Employee’s use of the emergency room on May 11, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for
the Employee’s use of the emergency room on May 11, 1992 because his symptoms had become severe necessitating immediate treatment.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s use of the emergency room on May 11, 1992 because the Employee’s symptoms had been present for two days and the emergency room record does not indicate that the symptoms had worsened or become severe in
the 48 hours immediately preceding the visit. Additionally, the Plan excludes procedures that can be performed with equal efficiency at a lower level of care.
Pertinent Provisions
Article III.A.(2)(a) of the Employer Benefit Plan states:
(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 that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.
The emergency room record indicates that the Employee had symptoms of an earache for two days prior to the emergency room visit. The Employee’s representative has stated that the emergency room was the only place the Employee could receive medical attention, although the service was provided on a Monday afternoon. A Funds’ medical consultant has reviewed the information presented in this case and has advised that the patient’s symptoms, as evidenced by the clinical presentation, were not acute and did not warrant emergency medical evaluation. Because the Employee did not have acute medical symptoms that warranted emergency medical treatment, the Trustees conclude that the Employer is not required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on May 11, 1992.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on May 11. 1992.