Opinion of Trustees
Resolution of Dispute
Case No. 84-694
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OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 fifteen-year-old daughter was taken to a hospital emergency room for medical evaluation and treatment at 1:00 p.m. on Monday, December 29, 1986. According to the hospital’s emergency room record, the Employee’s daughter had a sore throat for two days and a high temperature, headache and hearing loss over the previous 24 hours. The Employee’s daughter was tested for strep throat, and a blood count was obtained. She was diagnosed as having pharyngitis, and antibiotics were prescribed. The Employer paid the physician’s charge for evaluation and treatment and the hospital charges for the tests performed and the medication dispensed at the hospital. 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 required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on December 29, 1986?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on December 29, 1986, because treatment was sought within 48 hours of the onset of acute medical symptoms.
Employee
Employer
84-694 – May 17, 1989
Opinion of Trustees Resolution of Dispute Case No. 84-694
Page 2
Position of the Employer: The Employer is not required to pay the Employee’s daughter’s emergency room charge because the Employee’s daughter’s symptoms were not acute and because emergency medical treatment was not necessary.
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
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.
The Employer concedes that the emergency room visit was within 48 hours of the onset of symptoms. However, the Employer disputes that the Employee’s daughter had acute medical symptoms.
The Employee’s daughter’s symptoms were described in the emergency room record. It was noted the child suffered from a high temperature (1030 at home, the night before the visit), sore throat, headache and hearing loss. A medical consultant has reviewed the file and concluded that the child’s high temperature and hearing loss were significant symptoms that would reasonably indicate the need for emergency medical treatment to prevent serious complications. Test results indicating a high white blood cell count confirmed that the child had a serious infection. The consultant advised that, based on the evidence in this case, the patient’s acute medical symptoms warranted emergency medical treatment. Inasmuch as the Employee’s daughter received emergency medical treatment within 48 hours of the onset of acute medical symptoms, the Employer is required to pay the emergency room charge for the December 29, 1986 emergency room visit.
Opinion of the Trustees
The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on December 29, 1986.