December 11, 1979
(Opinion issued in letter form; name and address deleted)
Re: Resolution of Dispute
Case No. 85
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 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 hypertension
– 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.
At issue in this case is a question concerning the onset of acute symptoms. The above Question and Answer clarifies that benefits will be provided for emergency room services rendered within 48 hours of the onset of acute symptoms, even though the associated illness may be chronic or the onset of sub-acute symptoms may have occurred more than 48 hours earlier.
The emergency room record documents that the Employee had suffered with a cough, fever and chills for 3-4 days prior to the emergency room treatment. The Employee has stated however that it was the onset of severe chest and back pains which prompted him to contact the company nurse, who directed him to the local emergency room for evaluation and treatment. The emergency room record indicates that the attending physician ordered a chest x-ray and an EKG to be performed. The physician instructed the Employee to rest in bed and return in three days, or if the chest pains reoccurred. The chronology of the episode and the emergency room record indicate that the Employee was seeking emergency room treatment For the chest and back pains.
The nature of the emergency room evaluation, most notably the EKG, suggests the focus of diagnosis and treatment was on the acute back and chest pains, and not on the more longstanding sub-acute symptoms of his upper respiratory infection. The company nurse’s directive to the Employee to seek emergency room treatment further verifies the Employee’s position that the onset of the acute symptoms occurred and were treated within the 48 hour limitation. Thus, in accordance with the Q&A, it is our finding that the visit to the emergency room should be considered a covered benefit.
Sincerely,
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Harrison Combs, Chairman
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John J. O’Connell, Trustee
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Paul R. Dean, Trustee