OPINION OF TRUSTEES
ROD Case No. 88-225 – January 31, 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.
The Employee’s twelve-year-old daughter was taken to a hospital emergency room on April 19, 1989: According to the emergency room record, she had had a sliver in the fourth finger of her left hand for an unspecified length of time, and it had become infected. She was diagnosed with paronychia, an inflammation of the tissues surrounding the fingernail. 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 daughter’s evaluation and treatment on April 19, 1989?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on April 19, 1989.
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 Employee’s daughter’s injury and there is no evidence that acute medical symptoms requiring emergency treatment had developed within 48 hours prior the visit.
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.
The hospital records from the emergency room visit on April 19, 1989 indicate that the patient had injured the fourth finger of her left hand sometime prior to the visit and subsequently developed an infection. A Funds’ medical consultant has reviewed the hospital records and advised that paronychia is a very painful condition and can necessitate nail removal if not treated in its acute phase. The medical consultant is of the opinion that the patient’s wound required prompt surgical incision and drainage. The medical consultant has further noted that there is no documentation in the records of the onset or duration of symptoms, but given the nature of the patient’s condition (an inflammation) and the treatment rendered, it is reasonable to conclude that the patient’s symptoms had worsened within 48 hours preceding the visit in such a manner to indicate acute medical symptoms which warranted emergency medical treatment. Because the Employee’s daughter had developed acute medical symptoms that required emergency medical treatment within 48 hours of the emergency room visit, the Trustees conclude that the Employer is required to pay the emergency room charge.
Opinion of the Trustees
The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on April 19, 1989.