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OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Employee
Employer
88-732 – December 10, 1993
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 care under the terms of the Employer Benefit Plan.
Background Facts
On Sunday, December 13, 1992, the Employee sought medical evaluation and treatment for his sixteen-year-old daughter at the emergency room of a local medical center after she awakened with swelling and severe pain in the vaginal area. The emergency room record indicates that the symptoms began one week prior to the visit. The emergency room physician called in a surgeon, who performed an incision and drainage (I & D) on the abscess. The patient was given an antibiotic (Keflex), and instructed to follow-up with the surgical clinic in one week.
The Employer paid all other charges but denied benefits for the emergency department fee, stating that treatment was not received within 48 hours following the onset of acute medical symptoms.
Dispute
Is the Employer required to provide benefits for the emergency department charge resulting from the Employee’s daughter’s evaluation and treatment on December 13, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency department charge incurred on December 13, 1992 because the daughter’s symptoms had become more severe within the preceding 24 hours.
Position of the Employer: The Employer is not required to provide benefits for the emergency department charge resulting from the Employee’s daughter’s evaluation and treatment on
Complainant: Respondent: ROD Case No:
Board of Trustees:
Opinion of Trustees
ROD Case No. 88-732
Page 2
December 13, 1992 because the problem had begun a week earlier, and the emergency record does not indicate an exacerbation of the symptoms, therefore the use of the emergency room was not required.
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. The emergency record indicates that the symptoms had been present for a week and makes no mention that they had become more severe in the preceding 48 hours. The Employee, in his statement, states that the morning of the hospital visit his daughter had awakened in severe pain.
A Funds’ medical consultant has reviewed the medical records in this case and stated that abscesses of this type may continue to enlarge and can become very painful in a 24 to 48 hour period if they enlarge rapidly. The consultant further stated that even though the abscess partially drained while the child was waiting to be seen, the abscess still needed to be surgically opened and drained. He also stated that these abscesses can be more difficult to manage than other abscesses. Due to the enlargement of the abscess and the increased pain within the 48 hours prior to the visit, the consultant is of the opinion that the emergency room visit on December 13, 1992, was medically appropriate. Thus, the Trustees find that the Employer is required to provide benefits for the emergency room fee incurred by the Employee’s daughter on December 13, 1992.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room fee incurred by the Employee’s daughter on December 13, 1992.