OPINION OF TRUSTEES
ROD Case No: 84-687 – February 9, 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.
On April 30, 1987, the Employee sought evaluation and treatment at a hospital emergency room. The Employee states that he had been sick for two days prior to April 30, 1987. He states that he visited the emergency room on that date because he began to have chest pains. The Employee has a history of high blood pressure. According to the facility’s emergency room record, the Employee had complaints of flu symptoms, headache and sore throat. The Employee was diagnosed as having acute pharyngitis (sore throat) and flu syndrome. The Employer denied the charge for the use of the emergency room.
Is the Employer required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on April 30, 1987?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge, because treatment was medically necessary.
Position of the Employer: The Employer is not required to pay the emergency room charge because the Employee did not exhibit acute medical symptoms requiring emergency medical treatment.
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.
Under Article III. A. (2)(a) of the Employer Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms. Although the Employee states that he visited the emergency room because of chest pains, the emergency room record indicates that the Employee complained only of flu symptoms, headache and sore throat.
A Funds’ medical consultant has reviewed the clinical information presented in this case and has advised that the records of the attending physician’s examination indicate that the only abnormal finding was a congested throat. The consultant has stated that there was no evidence of acute medical symptoms that would warrant emergency medical treatment in this case. Because there is no evidence of acute medical symptoms, the Employer is not required to pay the emergency room charge.
Opinion of the Trustees
The Employer is not required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on April 30, 1987.