Opinion of Trustees
Resolution of Dispute
Case No. 84-508
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
84-508 – March 29, 1988
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.
The Employee has stated that his spouse became ill late on Friday evening, March 27, 1987, and that her symptoms progressively worsened. The Employee’s spouse visited the emergency room of a local clinic at 8:45 p.m., on Sunday night, March 29, 1987, with complaints of a sore throat, cough, earache in both ears, headache and aching all over. The Employee stated that he and his family always go to their physician’s office during regular office hours but that he felt this situation was an emergency, and his spouse could not wait until the next day to go to the physician’s office. The emergency room nurse recorded a temperature of 101.1°F and an elevated pulse of 108. The emergency room report indicates that patient had a red throat and swollen lymph nodes, was diagnosed with pharyngitis and tonsillitis, and was given an intramuscular injection of antibiotic and discharged on continued oral antibiotic therapy.
The Employer denied the emergency room charges stating that the need for treatment of acute medical symptoms in an emergency room had not been substantiated.
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on March 29, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on March 29, 1987 because the care was medically necessary.
Opinion of Trustees Resolution of Dispute Case No. 84-508
Position of the Respondent: The Employer is not responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on March 29, 1987 because the level of care rendered was not treatment 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, benefits are provided for medical treatment rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident. The Employee’s spouse went to a hospital emergency room at 8:45 p.m. on a Sunday evening complaining of a sore throat, cough, earache in both ears, headache and aching all over. The emergency room report states that she had a temperature above 101° and a pulse of 108. She was examined by a physician who prescribed an intramuscular injection of an antibiotic and diagnosed her condition as pharyngitis/tonsillitis.
The Employee’s statement that his spouse’s symptoms first occurred within the 48-hour period preceding the emergency room visit has not been disputed by the Employer. The Employer denied coverage of the emergency room charge stating that the care provided was not for the treatment of acute symptoms. The Employer cited Resolutions of Dispute 84-048, 84-316 and 84-352 as precedents for its position. In all three cases cited, the Trustees determined that the emergency room charges were not covered expenses because the patients had sought care for symptoms of more than 48 hours duration and, furthermore, the severity of their symptoms was not substantiated by their emergency room records. Therefore, there was no evidence in those cases that the need for care was acute, and none was provided by the examining physicians.
A Funds’ medical consultant has reviewed the records presented in this case and has advised that the symptoms presented warranted emergency medical treatment, which was in fact provided. Therefore, because the onset of symptoms occurred within 48 hours of the visit, and because the patient was treated for conditions which are reasonably categorized as acute, the emergency medical treatment rendered in this particular case is covered under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is responsible for payment of the emergency room charges result- ing from the Employee’s spouse’s evaluation and treatment on March 29, 1987.