Opinion of Trustees
Resolution of Dispute
Case No. 81-267
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
81-267 – September 27, 1983
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.
The issue of eligibility for Sickness and Accident Benefits was also raised in this dispute. Sickness and Accident Benefits, as set forth in Article XI of the 1950 Benefit Plan and Trust, are beyond the authority of the exemption granted to the Trustees by the Department of Labor and, therefore, cannot be addressed.
Background Facts
According to the information submitted, the Employee experienced episodes of “numbness on and off” for approximately one week prior to his emergency room visit. On February 2, 1983, he experienced an acute change in his condition when his left arm became “really cold and numb” and he began to experience “a big throbbing like pain” which radiated “up and down” his arm. Because of these new and acute symptoms he became concerned enough to seek medical attention. Since his personal physician’s office was closed, he sought care for those problems at the local emergency room. The Employer has denied the $28.00 charge for the emergency room.
Dispute
Is the Employer responsible for payment of emergency room charges?
Position of the Parties
Position of Employee: The emergency room charge should be a covered benefit since it was the only facility available for the evaluation of the acute medical symptoms he experienced.
Opinion of Trustees Resolution of Dispute Case No. 81-267
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Position of the Employer: The emergency room charge is not covered because this case cannot be considered a valid emergency medical situation requiring emergency treatment, since his symptoms were no different than any experienced the previous week.
Pertinent Provisions Article III. A.(2) (a) of the Employer’s Benefit Plan provides:
Benefits are provided for a Beneficiary who receives emergency medical treatment or medical treatment of an injury aa 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.
1981 Question and Answer #81-10 provides:
Subject: Definition of Emergency Treatment Benefit
References: Amended 1950 and 1974 Benefit Plans and Trusts, Article III,
Sections A (2) and A (3) (i)
Question:
Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident
- Would emergency treatment for conditions such as the following be covered under this provision?
- – acute pain attributed to gout?
- – heart attack, severe chest pain, or congestive failure experienced by a
patient with (chronic) heart disease?
- – intracranial bleeding or stroke experienced by a patient with hypertension?
- Are benefits provided for inpatient and outpatient hospital and physicians’ services following emergency treatment beyond the 48-hour initial care limit (for example, suture removal or cast removal)?
Answer:
- Yes, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic.
- Yes, if the follow-up treatment is covered under the Plan.
Opinion of Trustees Resolution of Dispute Case No. 81-267
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Discussion
Q&A #81-10 and Article III. A. (2) (a) of the Employer’s Benefit Plan provide that for emergency medical treatment to be a covered benefit, it must be rendered within 48 hours following the onset of acute medical symptoms.
The information presented in this case establishes that the Employee presented himself to an emergency room for evaluation of acute symptoms within 48 hours of their onset.
The Funds’ medical staff reviewed the clinical information presented in this case. They are of the opinion that the Employee’s symptoms did justify emergency medical treatment and/or evaluation.
Because it has been determined that the patient’s condition did warrant emergency medical treatment and because the treatment was rendered within 48 hours of the onset of acute symptoms, the Employer is responsible for payment or the emergency room charges.
Opinion of the Trustees
The Trustees are of the opinion that the Employer is responsible for payment of the emergency room charges.