Opinion of Trustees
Resolution of Dispute
Case No. 84-617
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OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
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 November 22, 1987, the Employee’s spouse sought medical evaluation and treatment at an emergency room of an ambulatory care center. According to the facility’s emergency room record, the Employee’s spouse had complaints of an earache in the left ear, ringing in both ears, tightness in the chest from a cough and a sore throat. The onset of these symptoms was recorded as four days prior to the emergency room visit. The Employee’s spouse was diagnosed as having sinusitis. The Employer denied charges related to the use of the emergency room on the grounds that emergency medical treatment was not sought within 48 hours of the onset of medical symptoms.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on November 22, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for the payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on November 22, 1987 because such treatment was medically necessary.
Employee
Employer
84-617 – May 10, 1988
Opinion of Trustees Resolution of Dispute Case No. 84-617
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Position of the Employer: The Employer is not responsible for payment of the emergency room charges because treatment was not rendered within 48 hours following the onset of acute medical symptoms.
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, providing 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: (3) Physician’s Services and Other Primary Care
(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 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
Under Article III. A. (2)(a) and Article III. A. (3)(i) of the Employer Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident. The emergency room record indicates that the onset of the Employee’s spouse’s symptoms occurred four days prior to the date she sought the emergency room services. There is no evidence to indicate that the Employee’s spouse’s symptoms had become acute or had changed within the 48 hours preceding the emergency room visit. Inasmuch as the Employee’s spouse did not seek treatment within 48 hours of the onset of acute medical symptoms, the Employer is not responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on November 22, 1987.
Opinion of Trustees Resolution of Dispute Case No. 84-617
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The Trustees note that on July 29, 1987, the Employee’s dependent daughter sought medical evaluation and treatment for asthma at an ambulatory care center. Initially, the Employer denied the payment of benefits for the visit but later provided coverage for it. Therefore, although the dispute as filed mentions service denied in July, that service is not in dispute.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on November 22, 1987.