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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
Employee
Employer
88-799 – May 3, 1995
In Re
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 December 10, 1992, the Employee’s six-year-old son was taken to a local hospital emergency room for evaluation and treatment. The emergency room record noted fever and sore throat that began three days prior to the visit, as well as nausea and vomiting that began the morning of the visit. The emergency room physician diagnosed the son’s illness as streptococcal pharyngitis, administered an intramuscular injection of Bicillin (a long-acting antibiotic), and prescribed Phenergan suppositories for home use.
The Employer provided benefits for the emergency room physician’s charge, but denied the charges for the emergency room and laboratory and pharmacy charges, stating that non- emergency care was rendered.
Dispute
Is the Employer required to provide benefits for the charges incurred as a result of the Employee’s son’s evaluation and treatment in the emergency room on December 10, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s son’s emergency room evaluation and treatment on December 10, 1992, because his symptoms had worsened in the 48 hours immediately preceding the emergency room visit, necessitating immediate care.
Opinion of Trustees Resolution of Dispute Case No. 88-799 Page 2
Position of the Employer: The Employer is not required to provide benefits for the charges incurred as a result of the Employee’s son’s emergency room treatment on December 10, 1992, because the symptoms had been present for three days, and did not represent a medical emergency.
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 emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.
The emergency room medical record indicates that the Employee’s son had a fever and sore throat for three days, and that he had developed nausea and vomiting the morning of the emergency room visit. A Funds’ medical consultant has reviewed the information in this case and notes that the Employee’s son’s fever had worsened to 103 degrees during the previous two days, and was 101.1 degrees at the time of the emergency room visit. The consultant states that of more significance was the fact that the Employee’s son had developed nausea and vomiting that morning; the physical examination and the strep screen were positive for streptococcal pharyngitis. The consultant notes that the patient had become toxic from the strep infection, as indicated by the higher fevers and the vomiting, which required an injection of a long-acting penicillin. The consultant further notes that toxic strep pharyngitis remains a serious illness in children, one that was sometimes fatal prior to the advent of antibiotics. Therefore, the consultant is of the opinion that the patient’s condition was clearly a medical emergency at the time of presentation, and required immediate care for acute medical symptoms that had worsened in the 48 hours prior to the emergency room visit.
Consistent with the provisions of the Plan, the Trustees conclude that the Employer is required to provide benefits for the emergency room and related charges incurred as a result of the Employee’s son’s evaluation and treatment on December 10, 1992.
Opinion of Trustees Resolution of Dispute Case No. 88-799 Page 3
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is required to provide benefits for the emergency room and related charges resulting from the Employee’s son’s evaluation and treatment on December 10, 1992.