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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-045 – December 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 twenty-one-year-old dependent son sought medical evaluation and treatment at a hospital emergency room at 9:24 pm. on March 23, 1988. The Employee has indicated that his son had fallen and injured his wrist earlier that evening. According to the hospital’s emergency room record, the Employee’s son was experiencing pain in his wrist, which had persisted for one week, and a mild fever and myalgias (muscle pains). The Employee’s son was diagnosed as having a viral syndrome and possible tendonitis in his wrist. The Employer denied the charges related to the use of the emergency room because it found no indication that the Employee’s son sought medical treatment as a result of acute medical symptoms or the occurrence of an accident, as required under the Employer Benefit Plan.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on March 23, 1988?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on March 23, 1988 because treatment was sought within 48 hours of the Employee’s son’s wrist injury.
Position of the Employer: The Employer is not responsible for payment of the Employee’s son’s emergency room charges because there is no indication that treatment was rendered within 48 hours of the onset of acute medical symptoms or the occurrence of an accident.
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 or the occurrence of an accident.
Although the Employee has indicated that his son fell at home and injured his wrist on the day of the emergency room visit, the emergency room record indicates that the patient had complained of wrist pain of one week’s duration. No injury is reported in the emergency room record.
A Funds’ medical consultant has reviewed the clinical information presented in this case pertaining to both components of the Employee’s son’s emergency room treatment. The consultant has advised that, by its nature, the patient’s mild viral type illness does not constitute an acute medical condition that requires emergency medical care. According to the consultant, the physician’s notes regarding the patient’s wrist indicate a tender area, but no swelling or pain on motion was noted. An x-ray of the wrist was negative, and the patient was discharged with a diagnosis of questionable tendonitis. The consultant has advised that, given the duration and the non-acute nature of the symptoms, the patient’s wrist did not require emergency medical attention. Because the emergency room care sought by the Employee’s son was not prompted by acute medical symptoms that required emergency treatment, the Employer is not responsible for payment of the emergency room charge resulting from the Employee’s spouse evaluation and treatment on March 23, 1988.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charge resulting from the Employee’s son’s evaluation and treatment on March 23, 1988.