OPINION OF TRUSTEES
ROD Case No: 81-430 – March 26, 1984
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 Employee is an active mine worker eligible for health benefits under the Employer’s Benefit Plan. On December 18, 1983, he presented himself for care at the emergency room of a local hospital.
The Employee states that, since he was “feeling so bad” and because he was unable to reach his physician, he went to the emergency room for treatment. The emergency room record indicates that the patient complained of cold symptoms, productive cough, and headaches which had become worse since 11:30 that morning. Apparently, the Employee had been under treatment for these problems since December 14, 1983. The diagnosis provided by the physician who evaluated the Employee in the emergency room was subacute viral nasopharyngitis with pansinusitis. The Employee was prescribed narcotic pain medication and a decongestant as treatment for this problem. The Employer has denied payment of the $45.00 emergency room charge.
Is the Employer responsible for payment of emergency room charges resulting from the Employee’s care on December 18, 1983?
Positions of the Parties
Position of the Employee: The emergency room charge should be considered a covered benefit.
Position of the Employer: The emergency room charge is not covered because the Employee’s complaints were not considered an emergency medical situation requiring emergency treatment, and because the Employee did not receive emergency care within 48 hours of the onset of symptoms.
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 as 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.
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) (a) and A (3) (i)
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.
1. 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?
2. 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)?
1. Yes, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic.
2. Yes, if the follow-up treatment is covered under the Plan.
Question and Answer #81-85 provides:
Subject: Follow-up Care to Emergency Treatment
References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (2) Ca) and (3) (i)
1. A beneficiary requires follow-up services to emergency treatment which are rendered beyond the 48-hour initial emergency care limitation, and which are also rendered in an emergency room. Are benefits provided for both the medical treatment and the emergency room charges?
2. A beneficiary requires emergency room treatment and receives it within 58 hours of the onset of acute symptoms. After the 48-hour period has expired the acute symptoms reappear. If the beneficiary goes to the emergency room for treatment within 48 hours of the reappearance of the acute symptoms, are benefits provided for both the medical treatment and the emergency room charges?
1. In this situation, the charge for emergency room service is not covered. However, benefits will be provided for charges for medical treatment which is otherwise covered under the Plan.
Q&A #81-10 and Article III A. (2) (a) of the Employer’s Benefit Plan provide that emergency medical treatment is a covered benefit if it is rendered within 48 hours following the onset of acute medical symptoms. Q&A #81-85 provides coverage for emergency room care within 48 hours of the reappearance of acute symptoms for which treatment had been previously provided.
The emergency room record indicates that the patient’s illness had been present for four days prior to the date he obtained emergency room treatment. However, this record also establishes that the Employee’s headache symptoms had become worse on the day he sought emergency care. It appears, therefore, that he received care within 48 hours following the onset `of acute medical symptoms. The Trustees note that the Employee attempted to contact his physician, but was unable to do so, prior to seeking care at the local emergency room.
A Funds’ medical consultant has reviewed the clinical information presented in this case and is of the opinion that the symptoms and clinical finding, as recorded, justify the Employee’s seeking emergency medical care. In addition, the consultant notes that the treating physician felt that the Employee’s headache was severe enough to require a prescription for a narcotic pain medication.
Because the patient’s condition did warrant emergency medical evaluation and because the treatment was rendered within 48 hours of the onset of acute symptoms, the Employer is responsible for payment of the emergency room charges.
Opinion of the Trustees
The Employer is responsible for payment of the emergency room charges.