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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-048 July 19, 1985
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee;, William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee.
Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 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 the provision of health benefits coverage for emergency room care under the terms of the Employer Benefit Plan. They hereby render their opinion on the matter.
Background Facts
The Employee is an active mine worker eligible for health benefits under the Employer Benefit Plan. On February 16, 1985, the miner presented himself at the emergency room of a local hospital for treatment. According to the miner, he was having increased difficulty with a head cold, and felt he needed to see a doctor at that time. The emergency room record indicates that the patient’s chief complaint was “head cold for one week”. There is no evidence that the miner’s visit to this facility was due to a change in his condition which occurred within the preceding 48 hours. The emergency room physician established that the patient had persistent symptoms of upper respiratory infection and diagnosed the miner’s problem as bronchitis. The Employer denied payment of the charges resulting from the miner’s emergency room care.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s evaluation on February 16, 1985?
Position of the Parties
Position of the Employee: The emergency room charge should be considered a covered benefit because, in his best judgment, the Employee sought care from the only facility available to render medical treatment at the time he felt he needed to be evaluated by a doctor.
Position of the Employer: The emergency room charge is not covered since this case cannot be considered a valid emergency medical situation requiring emergency treatment and because the onset of the symptoms for which the Employee sought care occurred at least five days prior to his emergency room evaluation.
Pertinent Provisions
Article III.A. (2)(a) of the Employer 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 an accident.
Article III.A. (3)(i) of the Employer Benefit Plan states:
When provided by a physician, benefits are provided for a beneficiary who receives outpatient emergency medical treatment or treatment of an injury as a 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.
Discussion
Article III.A. (2)(a) and Article III.A. (3)(i) of the Employer Benefit Plan establish 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 emergency room record indicates that the patient’s chief complaint of a head cold had persisted for one week prior to the date he obtained the emergency room treatment, and the record does not indicate that his medical symptoms had become acute or changed within the preceding 48 hours.
A Funds medical consultant has reviewed the clinical information presented in this case. It is his opinion that the symptoms and clinical findings, as recorded, did not justify emergency medical treatment.
Because it has been determined that the patient’s condition did not warrant emergency medical treatment since the treatment was not rendered with 48 hours of the onset of acute symptoms, the Employer is not responsible for the payment of the emergency room charges.
Opinion of the Trustees
The Employer is not responsible for the payment of the emergency room charges resulting from the Employee’s evaluation on February 16, 1985.