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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-365 – May 8, 1991
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 terms of the Employer Benefit Plan.
Background Facts
On Saturday January 6, 1990, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, the Employee’s spouse reported complaints of a sore throat, cold, ear infection, anorexia, dizziness and headache that had begun three days prior to the emergency room visit. The emergency room record also indicates that the Employee’s spouse had a temperature of 98.8. The Employee’s spouse states that she had called her physician seeking an appointment on Friday, the day before the emergency room visit. She was told that her physician could not see her until Monday and that she should go to the emergency room if her symptoms progressed. The Employee’s spouse states that she went to the emergency room on Saturday because she became very ill and had a high fever. The emergency room physician diagnosed the Employee’s spouse as having sinusitis. She was discharged with a prescription for an antibiotic and instructions to rest and to take Tylenol and plenty of fluids.
The Employee’s spouse’s physician has submitted a letter, confirming that the Employee’s spouse was advised on January 5, 1990 to go to the emergency room if her symptoms progressed. The physician also states in the letter that the Employee’s spouse had been advised in August 1988 to avoid caffeine and over-the-counter decongestants because of a history of heart palpitations.
The Employer has denied benefits for the charge related to the use of the emergency room on the grounds that the care provided the Employee’s spouse does not fall within the definition of medical emergency services under the Employer Benefit Plan.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on January 6, 1990?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge because her symptoms had worsened and the emergency room was the only facility available at that time for treatment.
Position of the Employer: The Employer is not required to pay the emergency room charge because the care the Employee’s spouse received does not fall within the definition of medical emergency services as defined by the Employer Benefit Plan.
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 sore throat, cold, ear infection, anorexia, dizziness and headache that had begun three days before the emergency room visit on January 6, 1990. The Employee’s spouse has stated that she went to the emergency room as advised by her physician because her symptoms had worsened. Although the Employee’s spouse has stated that one of her worsening symptoms was a high fever, emergency room records indicate that her temperature was 98.8 at the time of the visit.
A Funds’ medical consultant has reviewed the information presented in this case and has advised that there is no indication that the Employee’s spouse’s symptoms were acute or severe enough to warrant emergency medical care. According to the consultant, the patient’s past history of atrial fibrillation (palpitations), which was evaluated by her physician and determined benign in 1988, has no bearing on the emergency room visit in question in this case. 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 from the Employee’s spouse’s evaluation and treatment on January 6, 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 January 6, 1990.