Opinion of Trustees
Resolution of Dispute
Case No. 88-047
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-047 – 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.
Background Facts
The Employee’s dependent son was taken to a hospital emergency room for evaluation and treatment at 8:27 am. on January 17, 1988. The patient’s mother reported that the patient had awakened her at approximately 5:00 am. that morning complaining of abdominal pain. The pain continued for a few hours and rendered him unable to move about or walk. According to the hospital emergency room record, the Employee’s son had a history of diffuse abdominal pain for three days prior to the emergency room visit. The Employee’s son was treated and released and the emergency room physician advised his parents to bring him back if the pain increased.
At 10:14 pm. on the same day, the Employee’s son returned to the emergency room because the pain had persisted and was of such intensity that he was unable to sleep or move about. According to the emergency room record of the second visit, the Employee’s son had experienced crampy abdominal pain for two days. The Employee’s son was admitted to the hospital and diagnosed as having acute mesenteric adenitis. The admitting physician noted in the records that the Employee’s son’s “present condition started as sudden onset of abdominal pain two days prior to admission.”
The Employer paid the physician’s charge for evaluation and treatment related to the Employee’s son’s first hospital emergency room visit, but it denied the charge related to the use of the emergency room on the grounds that treatment was not rendered within 48 hours of the onset of acute medical symptoms, as required for coverage under Article III. A. (2) (a) of the Employer Benefit Plan.
Opinion of Trustees Resolution of Dispute Case No. 88-047
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There is no dispute regarding the Employer’s responsibility for payment of the charges related to the second emergency room visit and subsequent hospitalization.
Dispute
Is the Employer responsible for payment of the emergency room charge resulting from the evaluation and treatment of the Employee’s son at 8:27 a.m. on January 17, 1988?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the emergency room charge.
Position of the Employer: The Employer is not responsible for payment of the emergency room charge because the patient’s medical symptoms were not acute and treatment was not rendered within 48 hours of the onset of the symptoms.
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.
At 8:27 a.m. on January 17, 1988, the Employee’s son, complaining of abdominal pain, was taken to the emergency room. The child was treated and returned home but revisited the emergency room at 10:14 p.m. that same day. He was admitted to the hospital at that time. He was discharged on January 20, 1988.
The emergency room record for the 8:27 a.m. visit states that the Employee’s son had a three-day history of diffuse abdominal pain. That record, however, is inconsistent with an emergency room record prepared later that same day. The emergency room record for the 10:14 p.m. visit states that the Employee’s son had experienced two days of crampy abdominal pain. In addition, the History and Physical Examination Report and the Discharge Summary prepared in
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connection with the hospital admission that followed the 10:14 p.m. visit state that the child’s condition “started as sudden onset of abdominal pain two days prior to admission.”
A Funds’ medical consultant has reviewed the information presented in this case. He has stated that, in his opinion, the patient’s symptoms had changed within 48 hours preceding the 8:27 am. emergency room visit in such a manner that emergency medical treatment was warranted in this case. Inasmuch as the Employee’s son received emergency medical treatment within 48 hours following the onset of acute medical symptoms, the Employer is responsible for payment of the emergency room charge for the 8:27 a.m. emergency room visit.
Opinion of the Trustees
The Employer is responsible for payment of the emergency room charge resulting from the evaluation and treatment of the Employee’s son at 8:27 am. on January 17, 1988.