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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-342 – December 5, 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 for an Employee’s spouse under the Employer Benefit Plan.

Background Facts

On February 26, 1990, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room. The emergency room record indicates that the Employee’s spouse reported symptoms of a dry cough, sneezing and sore throat that had begun the previous day. The emergency room physician’s report indicates that the symptoms had worsened the day of the emergency room visit with frequent productive coughing spells, chest soreness on coughing, generalized body malaise, and a headache. The physician diagnosed the Employee’s spouse as having an upper and lower respiratory tract infection. He prescribed an antibiotic for treatment of the infection and a cough suppressant and decongestant for symptomatic relief.

The Employer provided benefits for the services of the emergency room physician and pharmacy but denied the charge related to the use of the emergency room on the grounds that the Employee’s spouse’s condition and treatment did not constitute an emergency medical situation.

Dispute

Is the Employer required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on February 26, 1990?

Positions of the Parties

Position of the Employee: The Employer is required to provide payment of the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on February 26, 1990.

Position of the Employer: The Employer is not required to provide payment of the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on February 26, 1990 because the Employee’s spouse’s condition did not constitute an acute emergency medical situation.

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 that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.

The emergency room record indicates that the Employee’s spouse had symptoms of a cough, sore throat and sneezing that had begun the day before the emergency room visit. The record also indicates that the cough had worsened the day of the visit and was accompanied by chest soreness, generalized body malaise and headache. A Funds’ medical consultant has reviewed the information presented in this case and has advised that the patient’s condition was not sufficiently severe to warrant an emergency room visit. According to the consultant, neither the history given by the patient nor the physician’s findings indicate that the patient had acute medical symptoms which required emergency medical treatment. Because there is no evidence of acute medical symptoms that warranted emergency medical treatment, the Trustees conclude that the Employer is not required to pay the emergency room charge resulting form the Employee’s spouse’s evaluation and treatment on February 26, 1990.

Opinion of the Trustees

The Employer is not required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on February 26, 1990.