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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-071 – January 13, 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
On July 3, 1988, the Employee’s twenty-one-year-old dependent son sought medical evaluation and treatment at a hospital emergency room. According to the facility’s emergency room record, the Employee’s son had complaints of a sore throat, fever, chills, and swollen glands. The onset of the symptoms was recorded as two to three days prior to the emergency room visit. The Employee’s son was diagnosed as having pharyngitis (sore throat) with lymphadenopathy (abnormal enlargement of the lymph nodes) and antibiotics and Tylenol were prescribed. The Employer denied charges related to the use of the emergency room stating that there was insufficient evidence to indicate that the Employee’s son’s medical symptoms had become acute prior to the emergency room visit.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on July 3, 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 July 3, 1988, because the Employee’s son’s symptoms were acute and emergency medical treatment was necessary.
Position of the Employer: The Employer is not responsible for payment of the Employee’s son’s emergency room charges because his medical symptoms were not acute and did not require 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 hour 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.
The emergency room record indicates that the onset of the Employee’s son’s symptoms occurred two to three days prior to the date of the emergency room visit. A Funds’ medical consultant has reviewed the records of the emergency room visit in question and advised that there is no indication that the Employee’s son’s symptoms had become acute or had progressively worsened within the 48 hours preceding the emergency room visit. The consultant advised that he found no evidence of acute medical symptoms that would warrant emergency medical treatment in this case. Therefore, the Employer is not responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on July 3, 1988.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on July 3, 1988.