Opinion of Trustees
Resolution of Dispute
Case No. 84-659
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OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

In Re

Employee
Employer
84-659 – October 12, 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’s two-year-old daughter was taken to a hospital emergency room for medical evaluation and treatment at 11:25 a.m. on Sunday, October 4, 1987. According to the hospital’s emergency room record, the Employee’s daughter was experiencing a cough and cold symptoms which began on October 3, 1987. The Employee’s daughter was diagnosed as having an acute respiratory infection and an ear infection, which required antibiotics for treatment. The Employer paid the physician’s charge for evaluation and treatment. The Employer denied the charges related to the use of the emergency room stating that the Employee’s daughter’s symptoms were not acute medical symptoms which necessitated emergency medical treatment, as required under the Employer Benefit Plan.

Dispute

Is the Employer responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on October 4, 1987?

Positions of the Parties

Position of the Employee: The Employer is responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on October 4, 1987 because treatment was sought within 48 hours of the onset of acute medical symptoms.

Opinion of Trustees Resolution of Dispute Case No. 84-659
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Position of the Employer: The Employer is not responsible for the Employee’s daughter’s emergency room charge because the patient’s medical symptoms were not acute and did not require emergency medical 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 emergency room record indicates that the onset of the Employee’s daughter’s medical symptoms occurred on the day prior to the emergency room visit on October 4, 1987. A Funds’ medical consultant has reviewed the records of the emergency room visit in question and advised that, in light of the family’s reports that the child was having difficulty breathing, the elevated pulse and respiratory rates constitute acute symptoms which would reasonably indicate the need for emergency medical treatment. The consultant stated that rapid breathing without fever in a two-year-old patient may be indicative of a serious medical problem involving the child’s lungs and would warrant emergency medical intervention. Inasmuch as the Employee’s daughter received emergency medical treatment within 48 hours following the onset of acute medical symptoms, the Employer is responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on October 4, 1987.

Opinion of the Trustees

The Employer is responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on October 4, 1987.