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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No.
In Re
Employee
Employer
88-214 – January 24, 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 health benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On April 29, 1989, the Employee sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, he complained of an itchy rash on his thighs which had begun one week earlier. The Employee was diagnosed with tinea cruris (fungal infection). In a note dated August 12, 1989, the emergency room physician stated that the Employee’s symptoms had become increasingly severe warranting immediate attention. 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 tee Employee’s evaluation and treatment on April 29, 1989.
Position of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge.
Position of the Employer: The Employer is not required to pay the emergency room charge because the Employee’s condition did not require emergency medical treatment and because
Opinion of Trustees Resolution of Dispute Case No. 88-214 Page 2
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 emergency room record indicates that the Employee’s symptoms of an itchy rash on his thigh had begun one week prior to the emergency room visit. Information contained in the file includes a note written four months after the visit by the emergency room doctor stating that the Employee’s symptoms had become increasingly severe. However, a Funds’ medical consultant has reviewed the clinical information presented in this file and advises that the Employee’s condition, tinea cruris, is a common fungal infection and that there is no documentation to indicate that it required emergency medical treatment. The medical consultant is of the opinion that the patient was not treated for acute medical symptoms in this instance. Because there is no evidence of the the existence of acute medical symptoms that warranted emergency medical treatment, the Trustees conclude that 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 April 29, 1989.