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OPINION OF TRUSTEES ____________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

在再保险

养老金领取者
雇主
11-0035 - 2013年3月27日

迈克尔·H. 荷兰，丹尼尔·L. Fassio和Marty D. 哈德逊

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

背景事实

The Complainant’s spouse sought medical treatment at the local emergency room on August 24, 2012, complaining of swelling and pain of her right hand. The pain was reported as 9 on a scale of 1 – 10. Emergency room records indicate the hand was swollen, 红肿且温暖, and the emergency room physician’s impression was acute cellulitis. Tests confirmed an elevated white blood count consistent with acute cellulitis rather than chronic lymphadema, a condition noted in the patient history notes. Respondent denied the charges associated with the visit to the emergency room, asserting that that the treatment was sought for a chronic condition, not for a medical emergency, and that the beneficiary could have sought treatment from her primary care physician.

争端

Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on August 24, 2012?

双方立场

Position of the Complainant: The Complainant’s spouse was experiencing extreme pain that occurred on the day treatment was sought. The charges are a covered benefit.

Position of the Respondent: The Complainant’s spouse did not seek medical attention from her primary care provider and the diagnosis does not indicate an emergency situation. The denial of the claim should be upheld.

Opinion of Trustees ROD Case No. 11-0035页

Pertinent Provisions 第三条.A(2)(a) of the 雇主 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.

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’s spouse had symptoms with an onset of 2 – 3 days prior to her admission and a history of chronic lymphadema, the acute symptoms occurred within 48 hours of admission and required emergency treatment. 因此, the charges associated with the visit to the emergency room on August 24, 2012, are a covered benefit under the terms of the 雇主 Benefit Plan.

的资金’ Medical Director notes that 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. 的资金’ Medical Director also notes that there is no requirement in the 雇主 Benefit Plan that a beneficiary see a personal care physician for acute medical symptoms prior to seeking emergency room medical treatment.

受托人的意见

根据第三条.A(2)(a) of the 雇主 Benefit Plan, Respondent is required to provide benefits for Complainant’s spouse’s emergency room visit on August 24, 2012.