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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-580 – October 21, 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.
Background Facts
The Employee sought medical evaluation and treatment at a hospital emergency room at 11:53 a.m. on May 7, 1987. The emergency room record lists the Employee’s symptoms as dyspnea (labored respiration), tightness across the chest, a productive cough with blood in the sputum, a sore throat, earache, fever and aching throughout his body. According to the record, the onset of symptoms was early that morning. The Employee was diagnosed as having acute bronchitis. He was treated with an injection of an antibiotic, given a prescription for an oral antibiotic and released.
The Employer paid the hospital’s pharmacy charge, but denied the charge for the emergency room services, stating that the record does not indicate that the Employees symptoms were acute and treatment was received during doctors’ normal office hours. The Employer states that an independent registered nurse reviewed the case and advised that the Employee’s symptoms are those of the common cold.
Dispute
Is the Employer responsible for payment of the emergency room charge resulting from the Employee’s evaluation and treatment or May 7, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the emergency room charge resulting from the Employee’s evaluation and treatment on May 7, 1987 because such treatment was medically necessary.
Position of the Employer: The Employer is not responsible for payment of the emergency room charge resulting from the Employee’s evaluation and treatment on May 7, 1987 because the Employee’s medical symptoms were not acute and aid not require emergency medical treatment.
Pertinent Provisions
Article III. A. (2)(a) of the Employer Benefit Plan states:
(2) Outpatient Hospital Benefits
(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 the accident.
Discussion
Article III. A. (2) (a) of the Employer Benefit Plan states that benefits are provided for a Beneficiary who receives emergency medical treatment provided such treatment is rendered within 48 hours following the onset of acute medical symptoms.
The emergency room record indicates that the onset of the Employee’s symptoms occurred during the morning of the emergency room visit on May 7, 1987. A Funds’ medical consultant has reviewed the clinical findings and has advised that there is no evidence of acute medical symptoms which would justify emergency medical treatment in this case. Because the emergency room care sought by the patient was not prompted by acute medical symptoms that were of an emergency nature, the Employer is not responsible for payment of the emergency room charge resulting from the Employee’s evaluation and treatment on May 7, 1987.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charge resulting from the Employee’s evaluation and treatment on May 7, 1987.