Opinion of Trustees
Resolution of Dispute
ROD Case No. 88-744
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OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-744 – December 15, 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 room charges under the terms of the Employer Benefit Plan.
Background Facts
On August 14, 1992, the Employee sought evaluation and treatment at a local hospital emergency room complaining of right ear pain and drainage that had been present for three days prior to the visit. The emergency room physician stated the diagnosis as right external otitis media (earache), prescribed an antibiotic and a pain medication, and told the Employee to see his private physician in a week if she had not improved.
The Employer provided benefits for the physician’s charges, but denied the emergency room facility charges, stating that the care could have been rendered in a physician’s office.
Dispute
Is the Employer required to provide benefits for the emergency room charges incurred as a result of the Employee’s evaluation and treatment on August 14, 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 August 14, 1992 because this was a certified medical emergency requiring immediate care in the emergency room.
Opinion of Trustees Resolution of Dispute ROD Case No. 88-744 Page 2
Position of the Employer: The Employer is not required to provide benefits for emergency room charges incurred by the Employee on August 14, 1992, because the symptoms had been present for three days and the care could have been rendered in a physician’s office.
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 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 patient complained of right external ear pain and drainage beginning three days prior to the emergency room visit. A Funds’ medical consultant has reviewed the information presented in this case and has advised that the patient’s symptoms had been present for 3 days with no medical documentation of worsening symptoms or new symptoms within 48 hours of the emergency department visit. For these reasons, the medical consultant is of the opinion that the emergency room visit would not be considered medically appropriate.
Because the Employee did not have acute medical symptoms that warranted emergency medical treatment, or continuing symptoms that became acute within 48 hours of the emergency room visit, the Trustees conclude that the Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on August 14, 1992. The Employer has, however, paid the emergency room physician’s charge associated with the visit.
Opinion of the Trustees
Opinion of Trustees Resolution of Dispute ROD Case No. 88-744 Page 3
The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on August 14, 1992.