Opinion of Trustees
Resolution of Dispute
Case No. 84-620
Page 1 ______________________________________________________________________________

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 health benefits coverage for hospital emergency room services received by the Employee’s spouse.

Background Facts

The Employee’s spouse was seen in the emergency room of a hospital on November 28, 1987 for back strain and chronic lower back pain, and on December 7, 1987 for back pain with disc herniation. On both visits she was treated with injections of narcotics. The Employee’s spouse has been treated for the past two years by an orthopedic surgeon. The orthopedic surgeon states that the patient has a history of back problems, including a bulging disc in the lower back, and that her visits to his office and the emergency room are appropriate. The Employee’s spouse states that the orthopedic surgeon does not stock narcotics in his office and that she has sought emergency room treatment only when injections are necessary to relieve her back pain.

The Employer denied the payment of benefits for the two emergency room visits because her condition was not acute. The Employer states that her condition is chronic and that she is frequently treated for it. The Employer claims that the Employee’s spouse should have been seen at a physician’s office and not in the emergency room of a hospital.

Dispute

Is the Employer responsible for payment of the charges for the Employee’s spouse’s emergency room visits on November 28, 1987 and December 7, 1987?

Positions of the Parties

Position of the Employee: The Employer is responsible for payment of the charges for the two emergency room visits because they were medically necessary.

Employee
Employer
84-620 – June 17, 1988

Opinion of Trustees Resolution of Dispute Case No. 84-620
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Position of the Employer: The Employer is not responsible for payment of the charges for the two emergency room visits because the emergency room services were used to treat a chronic medical problem rather than an acute medical condition.

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.

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.

1981 Contract Q&A #81-10 states:

Subject: Definition of Emergency Treatment Benefit

References:Amended 1950 and 1974 Benefit Plans & Trusts, Article III, Sections A (2) (a) and A (3) (i)

Question:

Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.

1. Would emergency treatment for conditions such as the following be covered under this provision:

– acute pain attributed to gout?

Opinion of Trustees Resolution of Dispute Case No. 84-620
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  • –  heart attack, severe chest pain, or congestive failure experienced by a patient with (chronic) heart disease?
  • –  intracranial bleeding or stroke experienced by a patient with hypertension?

2. Are benefits provided for inpatient and outpatient hospital and physicians’ services following emergency treatment beyond the 48-hour initial care limit (for example, suture removal or cast removal)?

Answer:

  1. Yes, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic.
  2. Yes, if the follow-up treatment is covered under the Plan. 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 such treatment is rendered within 48 hours following the onset of acute medical symptoms. Q&A #81-10 further clarifies that emergency room services are covered for the treatment of acute symptoms, even though an underlying medical condition may be chronic.

A Funds’ medical consultant has reviewed this file and advised that on both dates of service the Employee’s spouse had an acute exacerbation of back pain. In both instances, the Employee’s spouse was seen within 48 hours of the onset of the acute pain. During both visits, injections of narcotic pain relievers were administered, and on the second visit, a prescription for a narcotic pain pill was given. The emergency room record of the December 7, 1987 visit indicates that if the Employee’s spouse’s back pain had persisted, admission to the hospital would have been necessary to provide traction for the relief of the pain. Inasmuch as emergency medical treatment was rendered on both occasions within 48 hours following acute exacerbations of a chronic medical condition, the Employer is responsible for payment of the charges for the Employee’s spouse’s emergency room visits on November 28, 1987 and December 7, 1987.

Opinion of the Trustees

The Employer is responsible for payment of the charges for the Employee’s spouse’s emergency room visits on November 28, 1987 and December 7, 1987.