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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-627 – June 6, 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 has had recurrent neck and shoulder pain for two years. He states that he is unable to visit his physician during office hours, which are held only from 4:00 p.m. to 7:00 p.m., Monday through Friday, because the Employee’s work hours are 4:00 p.m. to 12:00 midnight, Monday through Friday. When the Employee called his physician with a complaint of neck pain, the physician instructed him to go to the hospital for x-rays of the cervical vertebrae and left shoulder and to meet the physician at the hospital emergency room for evaluation and treatment. After examining the Employee in the emergency room and reviewing the x-rays, the physician referred the Employee to another doctor. There is no record of additional treatment in the emergency room. The Employer provided health benefits coverage for the Employee’s x-rays but denied payment of the charges for the use of the emergency room facilities because there was no evidence of the onset of acute medical symptoms.
Dispute
Is the Employer responsible for the payment of the emergency room charges incurred by the Employee on January 13, 1988?
Positions of the Parties
Position of the Employee: The Employer is responsible for the payment of the emergency room charge incurred by the Employee for treatment rendered in a hospital emergency room on January 13, 1988. The treatment was medically necessary and the Employee was unable to see his physician during office hours because of his work schedule.
Position of the Employer: The Employer is not responsible for the payment of the emergency room charge incurred by the Employee on January 13, 1988 because there is no evidence of acute medical symptoms which warranted emergency room treatment.
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, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an 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 Employee visited the local emergency room for treatment because he had to work during his physician’s office hours. The Employee’s physician did not provide emergency medical treatment to the Employee, but provided care of a more routine nature. The use of the emergency room for such treatment represents the provision of care at an inappropriate level. The emergency room care sought by the Employee in this case was not prompted by the onset of acute medical symptoms and was not of an emergency nature. In this instance, the use of the emergency room facilities is not a covered service. Therefore, the Employer is not responsible for providing coverage for the emergency room charge incurred by the Employee on January 13, 1988.
Opinion of the Trustees
The Employer is not responsible for providing coverage for the emergency room charge incurred by the Employee on January 13, 1988.