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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-352 – July 17, 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.
Background Facts
On March 5, 1986, the Employee’s spouse presented herself at the emergency room of a local hospital for treatment. According to the information submitted, the Employee’s spouse had experienced cold symptoms for almost a week. She decided to seek treatment at the emergency room when minor chest pains accompanied her cold symptoms and “the thought of possible pneumonia entered her mind.” She did not have a family physician.
The emergency room record indicates that the patient’s chief complaint was “chills, aches all over, sore throat and headache, for the last week.” The emergency room physician stated that the patient had persistent symptoms of a mild throat infection, and diagnosed the spouse’s condition as sinusitis. The Employer paid the charges for the services of the emergency room physician but denied payment for the emergency room charge.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s spouse’s visit on March 5, 1986?
Positions of the Parties
Position of the Employee: The emergency room charge should be a covered benefit because the employee’s spouse sought medical treatment at a time when she believed she needed to be evaluated by a doctor.
Position of the Employer: The emergency room charge is not covered because there is no indication that emergency treatment was rendered within 48 hours following the onset of acute medical symptoms.
Pertinent Provisions
Article III. A. (2)(a) of the Employer Benefit Plan provides:
(a) Emergency Medical and Accident Cases
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:
(i) Emergency Treatment
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 provide that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.
The emergency room record indicates that the patient’s symptoms were related to a mild throat infection which the emergency room physician diagnosed as sinusitis. Although the Employee’s spouse states that mild chest pains associated with the cold symptoms prompted her visit to the emergency room, there is no documentation of a complaint of chest pain in the physician’s emergency room record, nor does the record indicate that the Employee’s medical symptoms had become acute or changed within the preceding 48 hours. The emergency room record, as well as the fact that the emergency room visit lasted only 15 minutes, indicate that the physician concentrated on evaluating the spouse’s complaint of “chills, aches all over, sore throat, and headache for the last week,” and not on mild chest pains, a symptom never documented by the medical record nor evidenced by the performance of tests such as a chest x-ray, blood tests or an electrocardiogram.
Because the emergency room care sought by the patient was not prompted by the onset of acute medical symptoms and was not of an emergency nature, the Employer is not responsible for payment of the emergency room charge.
Opinion of the Trustees
The Employer is not responsible for the payment of the emergency room charge resulting from the Employee’s spouse’s visit on March 5, 1986.