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OPINION OF TRUSTEES
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In Re
Complainant: Mine Worker
Respondent: Insurance Carrier
ROD Case No. 54 – September 21, 1979
Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust; and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning payment of emergency room charges and hereby render their opinion on the matter.
Background Facts
The Employee is an active mine worker eligible for health benefits under the Employer’s Plan. On Sunday, May 7, 1979, the Employee brought his spouse to the Emergency Room of a Hospital for treatment of an illness. Payment of the bill ($45.75) has been refused by the Employer’s insurer on the basis that the spouse did not go to the Emergency Room within 48 hours of onset of medical symptoms, as required by the terms of the plan. In this respect there is a dispute as to the facts. The Employee’s representative has stated that his spouse became ill on Friday, May 4 and it was impossible to take her to a doctor’s office at the hospital as they close as early as 3 p.m. on Friday and do not open again until Monday. The Employer’s insurer has submitted a copy of the Emergency Room record which contains the following hand written notations describing the spouse’s Complaint: “sore throat, nasal congestion, and cough – 5 days”. The diagnosis was: “URI (upper respiratory infection), acute gastritis, otitis media (inflammation of middle ear),” and acute urinary tract infection.
Dispute
This dispute concerns the refusal of the insurer to pay for Emergency Room services for a dependent of an Employee covered by an Employer’s plan established pursuant to Article XX of the NBCWA of 1978.
Positions of the Parties
Position of Employee’s Representative: The representative has stated that the Employer’s spouse became ill on Friday, May 4, 1979 and her condition worsened until she was brought to the Emergency Room on Sunday, May 6, because it was impossible for her to see a Doctor at regular hours.
Position of Employer’s Insurer: The insurer states that the benefits would have been paid without any question.if the Employee’s spouse had gone to the hospital within the 48 hour period. The insurer feels that the spouse did not go to the hospital until 5 days after onset of symptoms, and believes this position is verified by the Emergency Room record and by a call to the hospital to verify the information.
Applicable Regulations
Article III A(2)(a) which provides that benefits are provided for a Beneficiary who receives emergency medical treatment provided it is rendered within 48 hours following the onset of medical symptoms.
o 1978 Contract Q & A #48, as approved by the Trustees on May 17, 1978, provides as follows:
Question:
Benefits are provided for emergency treatment, provided the treatment is rendered within 48 hours following the onset of medical symptoms (or the occurrence of an accident). Would the following treatment be covered under this Provision:
– for acute pain attributed to gout?
– for heart attack, severe chest pain, or congestive failure experienced by a patient with (chronic) heart disease?
– for intercranial bleeding or stroke experienced by a patient with hypertension?
Answer:
Yes, since the symptoms are acute and require emergency treatment even though the illness ultimately causing the condition to be treated may be chronic.
Discussion
Q & A 45 further clarifies the 48 hour limitation on emergency room benefits by distinguishing between medical symptoms that are associates with chronic conditions and acute symptoms. It has been Funds policy to pay for emergency room service rendered within 48 hours of the onset of acute symptoms.
The medical record states that the patient’s U.R.I. had existed for 5 days but makes no mention of the time of onset for the acute urinary tract infection or the acute gastritis. Medical opinion provided to the Funds indicate that both the nature of these symptoms and the use of the word “acute” in the diagnosis of urinary tract infection and gastritis suggest that the onset of the acute symptoms occurred and were treated within 48 hour limitation cited in Q & A #45.
Opinion of the Trustees
The Trustees are of the opinion that the Insurance Carrier is required to cover the emergency room services incurred by the employee’s spouse.