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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Employee
Employer
88-784 – February 6, 1995
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 health benefits coverage for emergency room charges under the terms of the Employer Benefit Plan.
Background Facts
On Saturday, January 30, 1993, the Employee’s spouse sought evaluation and treatment at the emergency room of a local hospital complaining of left sided pain. According to the medical records, the spouse had a non-productive cough that had been present for the last three to four months. The medical record also notes that the Employee’s spouse’s left sided pain had increased beginning the day before, prompting the emergency room visit.
The emergency room physician ordered rib and chest x-rays, and a CBC (complete blood count), all of which proved to be normal. The Employee’s spouse was given an intramuscular injection of Demerol 50 mg. and Phenergan 25 mg. for her pain. The spouse was prescribed Ceftin 250 mg. (an oral antibiotic), and Tussinex 75 ml. (a cough syrup), and was discharged with orders to follow-up with a local pulmonary medicine group practice. The discharge diagnosis was chronic cough.
The Employer paid the charges for the emergency room physician, but denied the hospital facility charges on the basis that the care could have been rendered in a physician’s office. Additionally, the Employer states that the symptoms were not of an emergency nature, and that the treatment was not rendered within 48 hours of the onset of symptoms.
Dispute
Is the Employer required to provide benefits for the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on January 30, 1993?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-784 Page 2
Position of the Employee: The Employer is required to provide benefits for the emergency room charges resulting from Employee’s spouse’s evaluation and treatment on January 30, 1993, because her left sided pain had become more severe within the 48 hours immediately preceding the emergency visit.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s use of the emergency room on January 30, 1993, because the care could have been rendered in a physician’s office. Additionally, the symptoms were not of an emergency nature, and the care was not rendered within 48 hours of the onset of symptoms.
Pertinent Provisions
Article III.A.(2)(a) 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 benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and is of the opinion that although the patient had a cough and symptoms for three months, the medical record clearly indicates an acute onset of left sided chest pain that was sudden in onset and had been present for less than 12 to 24 hours. The consultant further stated that acute chest pain is clearly an indication for emergency department evaluation and, in his opinion, the visit in question would be medically appropriate.
The Trustees conclude that, consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the emergency room charges incurred by the Employee’s spouse on January 20, 1993.
Opinion of the Trustees
Opinion of Trustees Resolution of Dispute Case No. 88-784 Page 3
The Employer is required to provide benefits for the emergency room charges incurred by the Employee’s spouse on January 30, 1993.