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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-718 – February 6, 1995
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On April 15, 1992, the Employee sought medical evaluation and treatment for his twelve-year-old daughter at a hospital emergency room, stating she had difficulty hearing in both ears beginning the night before. The Employee’s spouse said that both an ear specialist and the daughter’s pediatrician were not available at that time.
The emergency room physician diagnosed the problem as bilateral cerumen impaction (wax in both ears), treated it with ear drops and irrigated both ears. The patient was discharged and told to continue using the ear drops.
The Employer denied benefits for the emergency room charge and related services, stating that the condition treated did not meet the definition of a medical emergency in the Employer Benefit Plan.
Dispute
Is the Employer required to provide benefits for expenses incurred by the Employee’s daughter in connection with her use of the emergency room on April 15, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s daughter’s use of the emergency room on April 15, 1992 because her ear condition required medical care and because the emergency room was the only available choice.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charges because the condition treated was not an emergency as defined by Article III. A. (2) (a) of the Employer Benefit Plan.
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 when the care is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.
The Employer denied the charges for the emergency room and related charges, stating that the Employee’s daughter’s condition did not meet the Plan definition for a medical emergency, and the emergency room record did not establish that the symptoms were acute.
A Funds’ medical consultant has reviewed the file and has stated that the medical records revealed that the patient had a cerumen blockage of both ears with no acute symptoms, only a history of decreased hearing. The consultant further stated that the decreased hearing would not qualify as an acute medical symptom. The consultant stated that, in his opinion, the use of the emergency room on April 15, 1992 would not be medically approporiate.
Therefore, the Trustees find that the Employee’s daughter’s use of the emergency room on April 15, 1992 would not be covered under the Employer Benefit Plan. Any physician’s charge or charges for laboratory tests or
X-rays, would, however, be eligible.
Opinion of the Trustees
The Employer is not required to provide benefits for emergency room charge incurred by the Employee’s daughter on April 15, 1992. The Employer is, however, required to provide benefits for any physician’s charges, or laboratory tests or X-rays in connection with the emergency room visit.