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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-699 – September 28, 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 benefits for emergency room treatment under the terms of the Employer Benefit Plan.
Background Facts
On Sunday, June 28, 1992, the Employee sought medical evaluation and treatment for symptoms of a urinary tract infection at the emergency department of a medical center. The emergency room physician diagnosed a urinary tract infection and treated and released the patient.
The Employer provided benefits for the physician’s fee, but denied the emergency room charge, stating that care had not been rendered within 48 hours of the onset of acute medical symptoms.
Dispute
Is the Employer required to provide benefits for the emergency room charge associated with the Employee’s medical evaluation and treatment on June 28, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge associated with the Employee’s medical evaluation and treatment on June 28, 1992 because the service is a covered benefit.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge associated with the Employee’s medical evaluation and treatment on June 28, 1992
Opinion of Trustees
ROD Case No. 88-699
Page 2
because there is no evidence in the medical record of acute symptoms requiring emergency treatment.
Pertinent Provisions
Article III. A. (2)(a) provides:
(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 rendered within 48 hours following the onset of acute medical symptoms. The Employer denied the emergency room charge for the Employee’s medical evaluation and treatment for symptoms of urinary tract infection on the basis that the emergency department record indicated that the symptoms had begun three days prior to the visit and had not worsened within 48 hours of the visit, and since care was not sought within 48 hours of the onset of acute medical symptoms, the emergency department charge is not a covered benefit. The Employer further stated the emergency department record indicated that the Employee had previously scheduled a medical appointment with his personal physician and that there is no evidence that the Employee could not have kept this appointment and been treated at a lower level of care with equal efficiency.
A Funds’ medical consultant has reviewed the records of the emergency room visit and has advised that the Employee had a past history of urinary tract infections (UTI). The consultant further stated that the record indicated that the symptoms had begun three days prior to the visit and that the symptoms had worsened with increasing frequency and were accompanied by fever. The consultant notes that UTI can become much worse if treatment is delayed for 24 to 48 hours. The consultant is of the opinion that the Employee’s Sunday, June 28, 1992 visit to the emergency department was medically appropriate. Because the Employee’s emergency department visit was prompted by acute symptoms that worsened within 48 hours of that visit, and was thus medically appropriate, the Trustees conclude that the Employer is required to provide benefits for the emergency room charge resulting from the Employee’s emergency room visit on June 20, 1992.
Opinion of the Trustees
Opinion of Trustees
ROD Case No. 88-699
Page 3
The Employer is required to provide benefits for the emergency department charge resulting from the Employee’s emergency room visit on June 28, 1992.