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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-671 – July 8, 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 benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On December 8, 1990, the Employee’s spouse sought medical evaluation and treatment for cough and congestion at a hospital emergency room. The emergency room nurses’ notes indicate that the patient had congestion and cough for one month. The emergency room record further indicates that the patient’s vital signs were normal. The emergency room physician treated the patient by prescribing medication.
The Employer provided benefits for the physician’s charge, but denied benefits for the emergency room charge.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on December 8, 1990?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred by the Employee’s spouse on December 8, 1990 because she visited the emergency room within 48 hours of the onset of acute medical symptoms.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s spouse on December 8, 1990 because there is no evidence that her symptoms were acute and required emergency medical treatment.
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
Under Article III. A. (2) (a) of the Employer Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours of the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and has advised that there is no documentation of new or worsening symptoms 48 hours prior to her visit. Further, given the documentation of normal vital signs including the patient’s temperature, no abnormal physical finding and a normal chest x-ray, the consultant is of the opinion that the Employee’s spouse’s emergency room visit was not medically appropriate.
Because there is no evidence that acute medical symptoms occurred within 48 hours of the Employee’s spouse’s emergency room visit, the Trustees conclude that the Employer is not required to provide benefits for the December 8, 1990 emergency room charge.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s spouse on December 8, 1990.