OPINION OF TRUSTEES
ROD Case No: 88-100 – May 30, 1989
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.
The Employee’s spouse was seen in the emergency room of a medical center on June 23, 1988 for treatment of depression. According to the facility’s emergency room record, the Employee’s spouse had a history of two previous psychiatric hospitalizations in 1986 for the treatment of major depression. The Employee has indicated that the Employee’s spouse’s physician advised the Employee’s spouse to go to the emergency room if she had a recurrence of symptoms. According to the emergency room record, she sought emergency room treatment on June 23, 1989 complaining of “bad nerves,” insomnia, and dry heaves. The Employer denied the charge related to the use of the emergency room.
Is the Employer required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on June 23, 1988?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge because the Employee’s spouse needed emergency treatment.
Position of the Employer: The Employer is not required to pay the emergency room charge because the Employee’s spouse did not exhibit acute medical symptoms requiring emergency medical treatment.
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.
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 or the occurrence of an accident.
A Funds’ medical consultant has reviewed the information presented in this case. The consultant advised that, although an increase in the patient’s depressive symptoms was documented and she was suffering from “bad nerves,” insomnia, and dry heaves at the time she sought medical treatment, the emergency room physician’s findings indicate that she was not suicidal, homicidal, overtly psychotic, nor otherwise acutely ill’ at that time. The emergency room physician prescribed an anti-depressant and sent the patient home. The consultant advised that he finds no evidence in the record of acute symptoms that required emergency medical treatment in this instance. Because there is no evidence of acute medical symptoms, the Employer is not required to pay the emergency room charge.
Opinion of the Trustees
The Employer is not required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on June 23, 1988.