Opinion of Trustees
Resolution of Dispute
Case No. 88-163
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-163 – December 20, 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 health benefits for emergency medical treatment under the terms of the Employer Benefit Plan.
Background Facts
On May 20, 1989, the Employee’s spouse sought treatment at a hospital emergency room because she was concerned about a knot in her right forearm that she had discovered the night before the visit. The emergency room records Indicate that one week prior to the visit she had injured her right forearm in a fall and had experienced normal bruising and pain In that arm. The emergency room physician ordered x-rays of the affected area and diagnosed the condition as a subcutaneous hematoma (a localized collection of blood under the skin). The emergency room physician Instructed her to take an anti-inflammatory medication as needed for pain and to use warm soaks on the area twice a day as needed. The Employer provided benefits for the x-ray and laboratory charges, but denied the physician’s charge and the charge related to the use of the emergency room.
Dispute
Is the Employer required to pay the physician’s charge and the emergency room charge resulting from the Employee’s spouse’s emergency room visit on May 20, 1989?
Positions of the Parties
Position of the Employee: The Employer is required to pay the charges resulting from the emergency room visit on May 20, 1989 because the Employee’s spouse was concerned that she might have developed a blood clot in her right forearm.
Opinion of Trustees Resolution of Dispute Case No. 88-163
Page 2
Position of the Employer: The Employer is not required to pay the charges resulting from the emergency room visit because the emergency room visit occurred more than one week after the Employee’s spouse’s injury.
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.
Article III. A. (3) (I) of the Employer Benefit Plan states: (3) Physician’s Services and Other Primary Care
(i) Emergency Treatment
When provided by a physician, benefits are provided for a Beneficiary who receives outpatient emergency medical treatment or 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) and Article III. A. (3)(I) 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 May 20, 1989 indicate that the Employee’s spouse injured her right forearm in a fall one week prior to the emergency room visit. The injury was unexceptional, and she experienced normal bruising and pain in her arm until the day before the emergency room visit when she discovered a new symptom, the knot in the bruised area, which prompted her to seek emergency medical treatment. The record indicates that the Employee’s spouse sought emergency medical treatment within 48 hours of the discovery of the knot on her forearm. A Funds’ medical consultant has reviewed the records of the emergency room visit and advised that the presence of such a knot is an acute symptom because it can be indicative of a blood clot, and emergency medical evaluation is warranted to
Opinion of Trustees Resolution of Dispute Case No. 88-163
Page 3
prevent possible complications. Therefore, the Trustees find that the Employer is required to pay the physician’s charge and the emergency room charge resulting from the Employee’s spouse’s emergency room visit on May 20, 1989.
Opinion of the Trustees
The Employer is required to pay the physician’s charge and the emergency room charge resulting from the Employee’s spouse’s emergency room visit on May 20, 1989.