____________________________________________________________________________

OPINION ____________________________________________________________________________

Complainant: Respondent: 连杆箱编号:

在再保险

员工
雇主
11-0032 - 2014年6月12日

致:Michael H. 霍兰德，马蒂·D. 哈德森和丹尼尔. 杰克

The facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan have been reviewed.

背景事实

The Complainant sought medical treatment at the local emergency room on May 28, 2012, complaining of a severe and worsening headache with high blood pressure. He was discharged with instructions to follow up with his primary care physician. 6月3日, 2012, the Complainant returned to the emergency room complaining of localized facial numbness. Emergency room records indicate that the numbness was limited to a small area at the left corner of his mouth and had not progressed since onset. It was also noted that the Complainant had not followed up with his primary care physician or contacted him over the 4-5 days since the numbness had begun. No other 出现了神经症状 and a CT scan was normal.

Respondent approved the charges associated with the May 28, 2012年去急诊室, 但否认了6月3日, 2012年费用, asserting that this was a non-emergency.

争端

Is Respondent required to provide benefits for Complainant’s emergency room visit on June 3, 2012?

双方立场

Position of the Complainant: The Complainant was experiencing facial numbness and went to the emergency room. This was a Sunday and the emergency room was the only available location for treatment. The charges are a covered benefit under the 雇主 Benefit Plan.

的意见
连杆箱编号. 11-0032页

Position of the Respondent: The claim was not submitted with an emergency diagnosis and is not a covered benefit. The denial of the claim should be upheld.

第三条有关规定.A(2)(a) of the 雇主 Benefit Plan states:

(2)医院门诊福利
(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.

第三条.A.(3)(h) of the 雇主 Benefit Plan states:

(3) Physicians’ Services and Other Primary Care (h) Home, Clinic, and Office Visits

Benefits are provided for services rendered to a Beneficiary at home, in a clinic (including the outpatient department of a hospital) or in the physician’s office for the treatment of illnesses or injuries, 如果由医生提供.

第三条.A.(3)(j) of the 雇主 Benefit Plan states:

(3) Physicians’ Services and Other Primary Care (j) Laboratory Tests and X-rays

Benefits will be provided for laboratory tests and x-rays performed in a licensed laboratory when ordered by a physician for diagnosis or treatment of a definite condition, 疾病或受伤.

讨论

第三条.A(2)(a) of the 雇主 Benefit Plan provides benefits for emergency medical treatment if the emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms. 的资金’ Medical Director reviewed the file, including the emergency room records, and determined that although the Complainant had been experiencing the problem for which he sought emergency room treatment for the previous 4 – 5 days, he had not sought treatment from his primary care physician. 除了麻木，没有别的

的意见
连杆箱编号. 11-0032页3

出现了神经症状. 的资金’ Medical Director opined that because the symptoms had an onset of more than 48 hours prior to the emergency room treatment, they are not a covered benefit under the terms of the 雇主 Benefit Plan.

The physicians’ charges and CT scan are covered benefits under 第三条.(A)(3)(h) and (j) of the 雇主 Benefit Plan.

Respondent’s consideration of non-emergent diagnosis discharge codes as the basis for determining the medical necessity or appropriateness of coverage of emergency medical treatment under the 雇主 Benefit Plan is not consistent with the terms, 规定, and requirements of the 雇主 Benefit Plan.

的意见

根据第三条.A(2)(a) of the 雇主 Benefit Plan, Respondent is not required to provide benefits for Complainant’s emergency room visit on June 3, 2012, 总计499美元.00. The 雇主 is responsible for the remaining physicians’ charges and radiological studies totaling 1,053.80.