Opinion of Trustees
Resolution of Dispute
Case No. 88-159
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-159 – January 16, 1990
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.
Background Facts
The Employee’s spouse has a chronic low white blood cell count, which makes her prone to serious infection. She developed a viral syndrome that persisted for several weeks and was unresponsive to treatment with different antibiotics. On Sunday, January 22, 1989, the Employee called his spouse’s primary physician because she was “very ill.” The physician concluded that her condition could be symptomatic of a serious problem and advised that she should go to the emergency room immediately. According to the emergency room record, the Employee’s spouse complained of headaches, abdominal pain, nausea and vomiting that had been persisting “on and off.” The Employee’s spouse underwent a battery of tests and was diagnosed with a viral syndrome. She was instructed to see her primary physician the following morning and was discharged.
The Employer denied the charge related to the use of the emergency room by the Employee’s spouse.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on January 22, 1989?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-159
Page 2
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on January 22, 1989 because the Employee’s spouse was very ill and emergency medical treatment was necessary.
Position of the Employee: 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
Article III. A. (2) (a) of the Employer Benefit Plan provides benefits for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.
The Employee’s spouse had a viral syndrome that had persisted for several weeks and was unresponsive to treatment. On the day of the emergency room visit, the Employee’s spouse’s symptoms of headache, abdominal pain, nausea, and vomiting worsened to a degree that caused her primary physician to send her to the emergency room. A Funds’ medical consultant has reviewed the documentation in this file and advised that the patient’s symptoms were an acute exacerbation of the persistent viral syndrome. The medical consultant further advised that, because the patient’s immune system was compromised by a chronic low white blood cell count, such acute symptoms would reasonably indicate the need for emergency medical care to prevent serious complications. Inasmuch as emergency medical treatment was rendered within 48 hours after the patient developed acute medical symptoms, the Employer is required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on January 22, 1989.
Opinion of the Trustees
The Employer Is required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on January 22, 1989.