Opinion of Trustees
Resolution of Dispute
Case No. 88-418
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
88-418 – November 20, 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 under the terms of the Employer Benefit Plan.
On February 26, 1991, the Employee’s spouse sought treatment at a hospital emergency room for symptoms of vaginal bleeding that had begun three days earlier, dysuria (painful urination) that had begun two days earlier, pain with intercourse, nausea, and abdominal pain that began the day of the visit. The emergency room physician ordered laboratory tests, a suppository for yeast Infection, and continued use of birth control pills. The physician gave a diagnosis of dysfunctional uterine bleeding with yeast infection, and recommended that she be seen for follow-up care at the gynecology clinic in two to three weeks. The Employer has paid all the charges pertaining to the visit, except those related to the use of the emergency room.
Is the Employer required to pay the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on February 26, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to pay the charge for the emergency room visit on February 26, 1991, because the Employee’s spouse’s condition had suddenly worsened to the point that emergency medical evaluation and treatment were necessary.
Position of the Employer: The Employer is not required to pay the charge for, the emergency room visit on February 26, 1991, because the Employee’s spouse s condition had been occurring on a regular monthly basis, the symptoms first appeared more than 48 hours prior to the visit, and the diagnosis indicates a non-emergency situation.
Opinion of Trustees Resolution of Dispute Case No. 88-418
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.
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.
A Funds’ medical consultant has reviewed this case. The consultant notes that the patient had been treated for a respiratory infection some weeks before the emergency room visit in question; however, the records indicate that the emergency room visit was prompted by the onset of urinary symptoms, vaginal bleeding with painful intercourse, and abdominal pain. He further notes that while no conclusive diagnosis was made other than dysfunctional uterine bleeding and yeast infections, the patient was sent for pelvic and urine cultures, a blood count and pregnancy test because of concern that she may have had a pelvic abscess. The Funds’ consultant has advised that the bleeding, the increase in symptoms and new symptoms of abdominal pain within 48 hours of the visit were acute medical symptoms which warranted emergency medical evaluation and treatment. Because the Employee’s spouse’s symptoms became acute within 48 hours of the emergency room visit and warranted emergency medical evaluation and treatment, 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 spouse’s evaluation and treatment on February 26, 1991.