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OPINION OF TRUSTEES ____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
Employee
Employer
02-042 – May 23, 2007
In Re
Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and Elliot A. Segal.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
Background Facts
Early April 5, 2006, at approximately 2:30 a.m., the Complainant’s spouse sought medical evaluation and treatment at a hospital emergency room (ER). ER records indicate the Complainant’s spouse reported sore throat symptoms and an inability to swallow, accompanied by a non-productive cough. Records indicate that the Complainant’s spouse’s throat had been sore for the preceding three-day period. In the ER, the Complainant’s spouse was treated by the emergency physician with injections of Rocephin, an antibiotic, and Decadron, a steroid, and discharged approximately one hour later. The Respondent has denied benefits for the charges associated with the ER visit.
Dispute
Is the Employer required to provide benefits for the $503.00 in charges connected with the ER visit of the Complainant’s spouse on April 5, 2006?
Positions of the Parties
Position of the Complainant: The Employer is required to provide benefits for the $503.00 in ER charges incurred by the Complainant’s spouse on April 5, 2006, because her symptoms were acute and there was no other facility available at that time for treatment.
Position of the Respondent: The Employer is not required to provide benefits for the ER visit since the treatment was not rendered at an appropriate level of care, services could have been provided at a more appropriate setting, the Complainant’s spouse presented at the ER with non- urgent symptoms, and the treatment was not rendered within 48 hours following the onset of acute medical symptoms.
Opinion of Trustees ROD Case No. 02-042 Page 2
Pertinent Provisions Article III A. (2) (a) of the 2002 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 care when rendered within 48 hours following the onset of acute medical symptoms. EE records indicate that the Complainant’s spouse had a sore throat with difficulty swallowing for the preceding 3 days. However, a statement from the Complainant’s spouse indicates a sudden increase in her difficulty swallowing. A statement from her daughter, a registered nurse, also confirmed the acuity and severity of her mother’s condition on the night of treatment. The Funds’ Medical Director has reviewed the medical records in this case and the above statements, and is of the opinion that her symptoms would cause her to seek emergency medical evaluation and care, and that the treatment given was consistent with the presence of an acute and severe condition. Therefore, the RODs that the Respondent cited in support of denying ER benefits do not apply here because the condition of the Complainant’s spouse was acute and ER treatment was an appropriate level of care. Additionally, the treatment was provided at a time when facilities other than the ER were not available. Consistent with the provisions of the 2002 Employer Benefit Plan, the Respondent is required to provide benefits for the ER visit by the Complainant’s spouse on April 5, 2006.
Opinion of the Trustees
Consistent with the provisions of the 2002 Employer Benefit Plan, the Respondent is required to provide benefits for the ER visit by the Complainant’s spouse on April 5, 2006.