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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-118 – September 25, 1989
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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.
Background Facts
On July 8, 1988, the Employee sought treatment at a hospital emergency room because he had discovered a lump behind his left knee that day. He had been having pain in his left leg when walking for two to three weeks prior to his emergency room visit, but he had continued working during this time. The Employee was diagnosed as having a cyst and/or musculoskeletal swelling behind his left knee and was discharged with an ace wrap bandage, a prescription for anti-inflammatory medication and instructions to follow up with an orthopedic physician, if necessary. The Employer denied the charge related to the use of the emergency room.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on July 8, 1988?
Position of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge because the Employee needed emergency treatment because he was concerned when he discovered the knot behind his left knee.
Position of the Employer: The Employer is not required to pay the emergency room charge 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
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.
The hospital records from the emergency room visit on July 8, 1988 indicate that the Employee had complaints of pain in his left leg for two to three weeks and that it had shown no improvement. The Employee sought emergency medical treatment when he noticed a lump on the back of his left knee on the day of his visit to the emergency room. A Funds’ medical consultant has reviewed the hospital records and advised that there is no evidence to indicate that the patient’s pain had increased in intensity or had changed within the 48 hours prior to the emergency room visit in such a manner that would require emergency medical treatment. The Employee states that he sought emergency medical treatment because he had noticed a lump on his leg earlier that day. The medical consultant is of the opinion that although potentially upsetting, the presence of such a lump is not an acute medical symptom that requires emergency medical treatment. Because there is no evidence of the onset of acute medical symptoms that required emergency medical treatment within 48 hours of the emergency room visit, the Trustees find 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 evaluation and treatment on July 8, 1988.