OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
84-330 – February 4, 1987
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 benefits for emergency room care under the terms of the Employer Benefit Plan.
On January 24, 1986, the Employee sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, the Employee’s condition was “non-urgent” and his complaints were “cold, sore throat, ears clogged, and upset stomach the day before.” The onset of these symptoms was recorded as January 18, 1986.
The Employer’s insurance carrier paid the physician’s charge for evaluation and treatment, but denied charges related to the use of the emergency room on the grounds that emergency medical treatment was not sought within 48 hours of onset of medical symptoms.
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s evaluation and treatment on January 24, 1986?
Position of the Parties
Position of the Employee: The Employee maintains that benefits for medical services received at the outpatient department of the hospital are owed him under the terms of the Coal Wage Agreement of 1984.
Opinion of Trustees Resolution of Dispute Case No. 84-330 Page 2
Position of the Respondent: The Employer maintains that benefits for emergency room services are not covered because they were not sought as a result of acute medical symptoms.
Pertinent Provisions Article III. A. (2) (a) of the Employer Benefit Plan states:
Benefits are provided for a beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, providing such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.
Under Article III. A. (2) (a) of the Employer Benefit Plan, covered medical emergency medical treatment must be rendered as a result of either an accident or acute medical symptoms. The emergency room record indicates that the patient’s flu-like symptoms first started six days prior to the date he obtained the emergency room services. The record also indicates that the Employee’s condition was “non-urgent” (as opposed to “emergency” or “urgent”). There is no evidence to indicate that the Employee’s symptoms had become acute within the 48 hours preceding the emergency room visit.
A Funds’ medical consultant has reviewed the clinical information presented in this case and is of the opinion that the symptoms and clinical findings did not justify emergency medical treatment. Since the Employee’s symptoms were not acute and had not changed within the preceding 48 hours in such a manner that would indicate a potentially acute situation, the emergency room treatment is not a covered benefit.
Opinion of the Trustees
The Employer is not responsible for the payment of the emergency room charges resulting from the Employee’s evaluation and treatment on January 24, 1986.