Opinion of Trustees
Resolution of Dispute
Case No. 88-064
Page 1 ______________________________________________________________________________
OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Employee
Employer
88-064 – January 13, 1989
In Re
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
On November 12, 1987, the Employee sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, the Employee was experiencing cramping abdominal discomfort, generalized aches, diarrhea and a low-grade fever which began on November 11, 1987. The Employee was diagnosed as having probable gastroenteritis. The Employer denied charges related to the use of the emergency room, stating that it found no evidence that the Employee’s symptoms had become acute or had changed within 48 hours of the emergency room visit and that no emergency medical treatment was rendered.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s evaluation and treatment on November 12, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the emergency room charges resulting from the Employee’s evaluation and treatment on November 12, 1987, because such treatment was medically necessary.
Opinion of Trustees Resolution of Dispute Case No. 88-064
Page 2
Position of the Employer: The Employer is not responsible for payment of the emergency room charges because emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms.
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
Article III. A. (2)(a) of the Employer Benefit Pian provides that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.
The emergency room record indicates that the onset of the Employee’s medical symptoms occurred on the day prior to the emergency room visit. A Funds’ medical consultant has reviewed the records of the emergency room visit in question and has stated that the record indicates that the Employee had significant symptoms of acute abdominal pain and a fever. The consultant stated that, given such symptoms, the Employee would not have known whether he was suffering from acute abdominal pain which might require emergency surgery or from ordinary gastroenteritis. The consultant is of the opinion that the emergency room visit in this case was prompted by the onset of symptoms that were reasonably judged to be acute and that emergency medical evaluation and treatment were warranted in this case. Inasmuch as the Employee received emergency medical evaluation and treatment within 48 hours following the onset of acute medical symptoms, the Employer is responsible for payment of the emergency room charges resulting from the Employee’s evaluation and treatment on November 12, 1987.
Opinion of the Trustees
The Employer is responsible for payment of the emergency room charges resulting from the Employee’s evaluation and treatment on November 12, 1987.