Opinion of Trustees
Resolution of Dispute
Case No. 88-435
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-435 – October 29, 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.
Background Facts
On January 27, 1991, the Employee’s spouse went to a hospital emergency room with symptoms of ear and throat pain. She was examined and antibiotics were prescribed. On February 13, 1991, the Employee sought treatment at a hospital emergency room for multiple symptoms, including burning throat, ear pain and productive cough with dark sputum. He was screened for streptococcal infection. The Employer denied the emergency room and the physician charges in both cases.
Dispute
Is the Employer required to provide benefits for the physician charges and emergency room charges resulting from the emergency room visits on January 27, 1991 and February 13, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to pay the charges resulting from the emergency room visits on January 27, 1991 and February 13, 1991 because both visits were for treatment of acute illnesses and occurred within 48 hours of the onset of symptoms.
Position of the Employer: The Employer is not required to pay the charges resulting from the emergency room visits on January 27, 1991 and February 13, 1991 because the diagnosis in each
Opinion of Trustees Resolution of Dispute Case No. 88-435
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instance does not indicate acute medical symptoms and in both cases the health insurance carrier determined that the symptoms did not require emergency treatment.
Pertinent Provisions 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 with 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
Article III. A. (3)(i) of the Employer Benefit Plan provides: (3) Physician’s Services and Other Primary Care
(i) Emergency Treatment
When provided by a physician, benefits are provided for a Beneficiary who receives outpatient emergency medical treatment or 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) and Article III. A. (3)(i) of the Employer Benefit Plan, benefits are provided for emergency medical treatment when such treatment is rendered within 48 hours following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the records of both of the emergency room visits in question. The consultant notes that both visits occurred within 48 hours of the onset of symptoms. The consultant has noted that the Employee’s spouse’s visit was prompted by acute ear pain and she was discharged on antibiotics. The consultant also noted that the Employee’s visit was prompted by multiple symptoms, including dark sputum, and screening was required for streptococcal infection. The consultant has advised that thee symptoms presented in both cases were of significant severity and would reasonably indicate the need for a patient to seek emergency medical evaluation and care.
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Inasmuch as emergency medical treatment was rendered within 48 hours of the onset of symptoms reasonably judged to be acute, the Employer is required to provide benefits under the Employer Benefit Plan for the physician charges and emergency room charges for the visits on January 27, 1991 and February 13, 1991.
Opinion of the Trustees
The Employer is required to provide benefits for the physician charges and emergency room charges resulting from the emergency room visits on January 27, 1991 and February 13, 1991.