Opinion of the Trustees ROD Case No. 87
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Employer (Insurance Carrier) Respondent: Employee (Union Official)
ROD Case No. 87, January 17, 1980
Board of Trustees: Harrison Combs, Sr., 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 about utilization of emergency room facilities and hereby render their opinion on the matter.
Complainant represents the company who provides health benefits to active mine workers covered under the Employer’s Plan. Specialist providers from a distant metropolitan area travel regularly to a smaller outlying community to treat employees for routine and/or follow up care which falls within the specialist’s area of expertise. These providers utilize the emergency room of the local hospital (as the site for treatment) in lieu of an office. The employees who seek treatment are billed for the physicians services, as well as the emergency room charges. The Insurance Carrier is allowing the physicians’ charges as visits, but for the applicable copayment. However, charges for the emergency room are being denied.
Question of Dispute
Is the practice of the Insurance Carrier to deny payment on the Emergency Room charges consistent with the provisions of the Employer’s Plan?
Position of Parties
Complainant (Employer Representative): The Insurance Carrier is allowing benefits for physician services, but for the copayment, Emergency Room charges are being denied in accordance with the provision of the Employer’s Plan which allows benefits for emergency room treatment only if the service is rendered within 48 hours of the onset of emergency medical symptoms or the occurrence of an accident. When the emergency room is used for routine and/or follow up care for a medical condition, benefits are not provided.
Respondent: The Insurance Carrier should provide benefits for the emergency room charges, as well as the physician services. Due to the fact that the services of specialists are not locally accessible, it is necessary to rely on the services of specialists visiting regularly from other cities to provide the necessary treatment. The charges incurred from the practice of these providers to utilize the local emergency room facilities as their offices should be allowed as a covered benefit, particularly in light of the fact that these specialists are providing an otherwise unavailable service.
Opinion of the Trustees ROD Case No. 87
o Article III Section A(2) of the Employer’s Plan, provides as follows:
Benefits are provided for a Beneficiary who receives emergency medical treatment or treatment of an injury as the result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of medical symptoms or the occurrence of the accident.
o 1978 Contract Question and Answer #45, 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.
Nothing in the 1978 Bituminous Coal Wage Agreement or the Employer’s benefit plan prevents the practice of the out-of-area specialists to use the local emergency room as the site for routine and/or follow up care for employees. The Plan only provides benefits for emergency treatment of an illness or injury rendered within 48 hours of the onset of medical symptoms. These specialist providers are not rendering services for emergency treatment, but providing care of a more routine and/or follow up nature.
Opinion of Trustees
The Trustees are of the opinion that the Insurance Carrier is not responsible for providing coverage for emergency room charges based on the facts of this case.