November 7, 1979
(Opinion issued in letter form; name and address deleted)
Re: Resolution of Dispute
Case No. 81
Pursuant to Article IX of the UMWA 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the U.S. Department of Labor, the Trustees have received a question concerning coverage for emergency room treatment of an Employee’s dependent under the Employer’s benefit plan. Their opinion is issued in Question and Answer form, as follows:
Subject: Definition of Emergency Treatment Benefit
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.
This Question and Answer clarifies the 48 hour limitation on emergency room benefits by distinguishing between medical symptoms that are associated with chronic conditions and acute symptoms. Benefits are provided for emergency room services rendered within 48 hours of the onset of acute symptoms.
Since your wife’s symptoms became acute within 48 hours of her Emergency Room visit, the visit should be considered a covered benefit.
Harrison Combs, Chairman
John J. O’Connell, Trustee
Paul R. Dean, Trustee