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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 93-096 – March 17, 2000
Trustees: A. Frank Dunham, Michael H. Holland, Donald E. Pierce, Jr. and
Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room treatment under the terms of the Employer Benefit Plan.
Background Facts
On July 3 and 4, 1997, the Employee visited his physician’s office for pain in his left ear. His physician diagnosed his condition as otitis media (ear infection) and prescribed an antibiotic. On July 5, 1997, the Employee went to the emergency room because his physician was unavailable and he felt that his condition had gotten worse.
The Employer’s insurance carrier denied benefits stating that the emergency room treatment was not an appropriate level of care and that the care should have been rendered in a physicians office.
Dispute
Is the Employer required to provide benefits for the Employee’s emergency room treatment?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s emergency room treatment because it was medically necessary.
Position of the Employer: The Employer has not replied to repeated correspondence from Funds’ staff requesting its position in this dispute.
Pertinent Provisions
The Introduction to Article III states in pertinent part:
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan . . . . Services which are not reasonable and necessary shall include, but are not limited to the following: . . . procedures which can be performed with equal efficiency at a lower level of care.
Article III A. (2) (a) of the Employer Benefit Plan states:
A. Health Benefits
(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
The Introduction to Article III states that covered services shall be limited to those services which are reasonable and necessary, and which are given at the appropriate level of care. The Introduction also states that services that are not reasonable and necessary shall include procedures which can be performed with equal efficacy at a lower level of care. Article III A. (2) (a) provides benefits 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 documentation submitted with this case and has concluded that the treatment prescribed by the Employee’s physician was adequate for the Employee’s condition and that the emergency room records do not document any new treatment or acute symptoms that would justify emergency treatment. Therefore, the Employer is not required to provide benefits for the Employee’s emergency room treatment on July 5, 1997.
Opinion of the Trustees
Consistent with the provisions of the 1993 Employer Benefit Plan, the Employer is not required to provide benefits for the Employee’s emergency room treatment on July 5, 1997.