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OPINION OF TRUSTEES
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In Re

Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-462 – March 20, 1992

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 charges under the terms of the Employer Benefit Plan.

Background Facts

On September 20, 1989, the Pensioner’s spouse was taken to the emergency room due to swelling, pain, and discoloration of her right foot/ankle. The history reveals no trauma to this area. According to the Pensioner’s statement, his spouse’s pain was so severe that it radiated all the way to the hip. She sought treatment in the emergency room because she was concerned about the possibility of a blood clot. The Employer denied the emergency room charges, stating that the diagnosis was not that of an acute medical emergency.

Additionally, On January 8, 1990, the Pensioner’s spouse was taken to the hospital complaining of chest pains, pain in her neck, and pain radiating down her left arm. She was seen in the emergency room by two doctors, one of whom was her family physician. While the first physician’s final diagnosis was atypical right arm, shoulder and neck pain and carpal tunnel syndrome, the emergency room record reveals that he ordered and performed tests that would rule out cardiac involvement. The family physician’s note on the emergency room record indicates he did not feel that the pain was caused by the carpal tunnel syndrome. He suggested treatment with nitroglycerine and possibly a treadmill EKG. The Employer denied the emergency room charge because the diagnosis did not indicate an acute medical emergency.

Dispute

Is the Employer responsible for payment of the emergency room charges resulting from the evaluation and treatment of the Pensioner’s spouse on September 20, 1989 and January 8, 1990?

Positions of the Parties

Position of the Employee: The Employer is responsible for payment of the emergency room charges resulting from the evaluation and treatment of the Pensioner’s spouse on September 20, 1989 and January 8, 1990, because emergency medical treatment for acute medical conditions was required in each instance.

Position of the Employer: The Employer is not required to provide payment for the emergency room charges resulting from the Pensioner’s spouse’s evaluation and treatment on September 20, 1989 and January 8, 1990, because the Pensioner’s spouse’s conditions did not constitute acute emergency medical situations. The Employer has cited Article III. A (2) (a) and Article III. A (3)(i) of the Employer Benefit Plan and ROD Cases 88-342 and 88-389 in support of its position.

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 or the occurrence of an accident.

The emergency room records of September 20, 1989 indicate that the Pensioner’s spouse reported pain and swelling of the right foot with pain radiating to the hip. The record indicates that there was no history of trauma and that the symptoms started that morning. A Funds’ medical consultant has reviewed the information presented in this case and has advised that even if the physician felt confident that there was no evidence of a blood clot from the symptoms and physical findings, it was a reasonable concern for the patient and it was prudent to seek evaluation for a potentially emergent condition. For this reason, the Funds’ medical consultant has advised that the emergency room visit was warranted for evaluation and treatment of symptoms reasonably considered to be acute. , Therefore, the Trustees conclude that the Employer is required to pay the emergency room charges resulting from the Pensioner’s spouse’s evaluation and treatment on September 20, 1989.

The emergency room record for January 8, 1990 indicates that the Pensioner took his spouse to the emergency room with complaints of right arm, neck and shoulder pain. A Funds’ medical consultant has reviewed the information presented in this case and notes that the initial treating physician was concerned about atypical cardiac pain and ordered an EKG and cardiac enzymes. The consultant further notes that a second physician felt the pain warranted nitroglycerine by mouth, a chest x-ray, and also checked that the pain was not caused by carpal tunnel syndrome. The consultant has advised that the patient’s atypical pain was clearly considered to be possible cardiac pain by both examining physicians, and that the visit on January 8, 1990 was therefore warranted for evaluation and treatment of acute medical symptoms. Inasmuch as the Employee’s spouse was evaluated and treated for acute medical symptoms, the Employer is required to pay the emergency room charges resulting from the Pensioner’s spouse’s evaluation and treatment on January 8, 1990.

Opinion of the Trustees

The Employer is required to pay the emergency room charges resulting from the Pensioner’s spouse’s emergency room visits on September 20, 1989 and January 8, 1990.