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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-707 – January 16, 1990
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
On May 24, 1987, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, the Employee’s spouse complained of a chest cold and congestion that had begun on May 20, 1987 and that was unrelieved by antibiotics. The Employee’s spouse’s body temperature had risen on May 23, 1987. According to the record, the patient’s left lung had been removed previously. The emergency room physician diagnosed the Employee’s spouse’s condition as bronchitis and instructed her to take a decongestant cough medicine.
On September 6, 1987, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, the Employee’s spouse had been experiencing pain in her hip, lower back, left ribs and left shoulder since August 30, 1987. The emergency room physician ordered x-rays of the left hip and sacroiliac joint and diagnosed the Employee’s spouse’s condition as arthralgia (joint pain) or neuralgia (nerve pain), scheduled her for physical therapy and discharged her with prescriptions for a tranquilizer, antidepressant and analgesic/anxiolytic.
On October 4, 1987, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, the Employee’s spouse had had a pruritic (itchy) rash on her trunk since September 27, 1987. The emergency room physician diagnosed the Employee’s spouse’s condition as allergic dermatitis and instructed her to take an antihistamine, to stop using cortisone cream and to follow-up with her personal physician.
On November 11, 1987, the Employee sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, the Employee complained of chest
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pain, nausea and vomiting that had begun that same day, According to the record, the patient had a medical history of orthostatic hypotension (drop in blood pressure with change in position) and was on cardiac medications. The emergency room physician examined the patient and spoke with his personal physician. The emergency room physician instructed the patient to see his personal physician the following day for further workup and treatment.
The Employer denied the charges related to the use of the emergency room for all four visits. Dispute
Is the Employer required to pay the emergency room charges resulting from the Employee’s spouse’s emergency room visits on May 24, 1987, September 6, 1987 and October 4, 1987 and the Employee’s emergency room visit on November 11, 1987?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charges for all four visits because the services were rendered within the guidelines for coverage under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to pay the emergency room charges for the Employee’s spouse’s visits on May 24, 1987, September 6, 1987 and October 4, 1987 because in each instance medical treatment was not rendered within 48 hours of the onset of her symptoms.
The Employer is not required to pay the emergency room charge for the Employee’s visit on November 11, 1987 because he did not receive services that could be considered emergency medical treatment.
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
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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.
A Funds’ medical consultant has reviewed the clinical information pertaining to all four emergency room visits in question. The May 24, 1987 emergency room record indicates that the patient had experienced symptoms of a chest cold and congestion since May 20, 1987 and had begun taking an antibiotic for the treatment of upper respiratory problems on May 21, 1987. The consultant advises that there should have been a significant improvement in her symptoms within 48 hours (by May 23, 1987), but instead the patient’s temperature had risen on May 23, 1987. The consultant is of the opinion that the patient’s condition had worsened within 48 hours of the emergency room visit on May 24, 1987. The consultant further advises that, because the patient has only one lung, her worsening respiratory problems constitute acute symptoms that would reasonably indicate the need for emergency medical care. Inasmuch as emergency medical treatment was rendered within 48 hours following the onset of acute medical symptoms, the Trustees find that the Employer is required to pay the emergency room charge incurred on May 24, 1987.
The September 6, 1987 emergency room record indicates that the Employee’s spouse had experienced pain in her hip, lower back, ribs and left shoulder for one week prior to the visit. The medical consultant advises that there is no indication of any increase in the intensity of the pain or any changes in the patient’s symptoms during the 48 hours preceding the emergency room visit. The consultant is of the opinion that the patient’s complaints were not acute medical symptoms. Inasmuch as emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms, the Trustees find that the Employer is not required to pay the emergency room charge incurred on September 6, 1987.
The October 4, 1987 emergency room record indicates that the Employee’s spouse had had a pruritic (itchy) rash on her trunk for eight days prior to the visit. The medical consultant advises that there is no evidence of acute medical symptoms that would warrant emergency medical treatment in this instance. Inasmuch as emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms, the Trustees find that the Employer is not required to pay the emergency room charge incurred on October 4, 1987.
The November 11, 1987 emergency room record indicates that the Employee complained of chest pain, nausea and vomiting that had begun earlier that day. The patient has a history of orthostatic hypotension and was on cardiac medications. The medical consultant is of the opinion that the emergency room visit in this instance was prompted by the onset of symptoms that were reasonably judged to be acute and emergency medical treatment was warranted to evaluate the seriousness of the patient’s condition and to prevent further complications. The Employer contends that the Employee did not receive services that can be considered “emergency medical treatment.” However, the emergency medical treatment provided in this instance consisted of the emergency room physician’s evaluation and referral for follow-up care. Inasmuch as emergency medical treatment was rendered within 48 hours following the onset of acute medical symptoms,
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the Trustees find that the Employer is required to pay the emergency room charge incurred on November 11, 1987.
Opinion of the Trustees
The Employer is required to pay the emergency room charges resulting from the Employee’s spouse’s emergency room visit on May 24, 1987 and the Employee’s emergency room visit on November 11, 1987. The Employer is not required to pay the emergency room charges incurred by the Employee’s spouse on September 6, 1987 and October 4, 1987.