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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-642 – August 25, 1988
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dear, 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 December 27, 1987, the Employee sought medical evaluation and treatment at a hospital emergency room for intense pain in his left hand because his doctor was unavailable. According to the hospital’s emergency room record, he had been experiencing pain in the left hand and wrist for four days. According to the record, the Employee had hit the back of his hand three weeks prior to his visit to the emergency room.
The Employer denied charges related to the emergency room visit 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 evaluation and treatment on December 27, 1987?
Positions of the Parties
Position of the Employee: The Employee maintains that he sought emergency room treatment for acute medical symptoms when he could not contact his own physician and that the related charges should therefore be covered.
Position of the Employer: The Employer maintains that the emergency room treatment was not rendered within 48 hours following the onset of acute medical symptoms and that the emergency room charges resulting from the Employee’s evaluation and treatment on December 27, 1987 should therefore not be covered.
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 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 indicates that the Employee had pain in his left hand and wrist for four days prior to his emergency room visit. Although the Employee states that intense pain which rendered the hand non-functional prompted his visit to the emergency room, there is no substantiation on the emergency room record of the severity of the pain, that the hand was non- functional, or that the symptoms had changed during the 48 hour period prior to the visit.
A Funds’ medical consultant has reviewed the clinical information presented in this case and is of the opinion that there is insufficient documentation to establish that the onset of acute symptoms occurred within 48 hours prior to the emergency room visit. Therefore, the Employer is not responsible for payment of the emergency room charge resulting from the Employee’s evaluation and treatment on December 27, 1987.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charge resulting from the Employee’s emergency room evaluation and treatment on December 27, 1987.