______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-680 – January 25, 1989
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 28, 1987, the Employee’s eight-year-old daughter was taken to a hospital emergency room for medical evaluation and treatment. The Employee’s spouse states that the visit occurred within 48 hours of the onset of her daughter’s symptoms. According to the hospital’s emergency room record, the Employee’s daughter had complaints of nasal congestion and generalized aching of three to four days duration. The Employee’s daughter was diagnosed as having a viral syndrome. 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 the medical symptoms.
Dispute
Is the Employer responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on November 28, 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 November 28, 1987 because treatment was sought within 48 hours of the onset of acute medical symptoms.
Position of the Employer: The Employer is not responsible for payment of the Employee’s daughter’s emergency room charge because treatment was not sought within 48 hours of the onset of acute medical symptoms.
Opinion of Trustees Resolution of Dispute Case No. 84-680 Page 2
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 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.
While the Employee’s spouse states that the emergency room visit in this case occurred within 48 hours of the onset of her daughter’s symptoms, the emergency room record clearly indicates that the child’s symptoms began three to four days prior to the emergency room visit. In addition, a Funds’ medical consultant has reviewed the information presented in this case and has advised that the child was afebrile (free from fever) and did not appear to be acutely ill at the time of the visit. Therefore, the Employer is not responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on November 28, 1987.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on November 28, 1987.