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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-592 – August 31, 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 aid 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’s spouse was seen in the emergency room of a medical center on September 5, 1987 at 11:15 p.m. for treatment for irregular vaginal bleeding, which had persisted for over one month. She was diagnosed with menometrorrhagia, abnormally profuse menstrual flow and bleeding between menstrual periods, and probable pelvic inflammatory disease. She was given prescriptions for two oral medications and released.
The Employee’s four-year-old dependent daughter was seen in the emergency room of a medical center on October 16, 1987 at 6:37 p.m. for treatment for coughing, which had persisted for one week. She was diagnosed as having an upper respiratory infection, and her mother was instructed to give her a decongestant.
The Employer denied the charges related to the use of the emergency room for both visits, stating medical treatment was not rendered within 48 hours of the onset of symptoms as required under Article III. A. (2) (a) of the Employer Benefit Plan.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the respective evaluations and treatments rendered the Employee’s spouse and daughter on September 5, 1987 and October 16, 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 dependents’ evaluations and treatments on September 5, 1987 and October 16, 1987 because treatment was necessary and the clinic where they are normally treated was closed.
Position of the Respondent: The Employer is not responsible for payment of the Employee’s dependents’ emergency room charges because medical treatment was not rendered within 48 hours of the onset of symptoms as required under the Plan.
Pertinent Provisions
Article III. A. (2) (a) of the Employer Benefit Plan provides:
(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, providing 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 provides 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 of September 5, 1987 indicates that the onset of the Employee’s spouse’s irregular bleeding had occurred during the month prior to the emergency room visit. Nothing in the record indicates that the spouse sought emergency room treatment because the problem had become worse or acute during the preceding 48 hours. The emergency room record of October 16, 1987 indicates that the Employee’s daughter had no fever and that the onset of her “cold-like” symptoms occurred one week before her emergency room visit. Since there is no evidence to indicate that either of the Employee’s dependent’s medical symptoms had become acute or had changed within the 48 hours preceding the emergency room visit and inasmuch as the Employee’s daughter did not seek treatment within 48 hours of the onset of medical symptoms, the Employer is not responsible for payment of the emergency room charges.
The Trustees note that although the dispute as filed mentions benefits denied for service on September 1, 1987, that service is no longer in dispute. The Employee’s spouse sought medical evaluation and treatment for pharyngitis at the emergency room of a medical center. Initially- the Employer denied the payment of benefits for the service in question, but later provided coverage for it.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charges resulting from the respective evaluations and treatments rendered the Employee’s spouse and daughter on September 5, 1987 and October 16, 1987.