Opinion of Trustees
Resolution of Dispute
Case No. 88-470
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-470 – September 21, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. Segal, 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 May 6, 1991, the Employee sought medical evaluation and treatment for his fourteen-year- old son at the emergency room of a medical center. According to the emergency room record, the Employee’s son complained of a severe headache of two hours duration. A week earlier, the patient had been treated for bronchitis and sinusitis at another facility. The emergency room physician examined the patient to rule out meningitis and prescribed Entex, Bactrim D.S. and Tylenol #3.
The Employer provided benefits for the physician charge, but denied the emergency room charge incurred on May 6, 1991.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s son’s evaluation and treatment on May 6, 1991?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-470
Page 2
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred on May 6, 1991 because acute symptoms appeared within 48 hours of the emergency room visit.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s son’s evaluation and treatment on May 6, 1991 because there is no evidence of an acute medical problem that required emergency treatment.
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
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 the medical records in this case and has pointed out that the emergency room record states that the patient had complained of a severe headache for two hours prior to the emergency room visit. The fact that he had been treated for bronchitis and sinusitis the previous week does not negate the evidence that a new symptom warranting emergency medical care existed. The consultant emphasized that the patient was only fourteen years old. Given the patient’s age and the fact that the emergency room physician treated the symptoms aggressively with Entex LA, Bactrim D.S., and Tylenol #3, the consultant is of the opinion that the visit to the emergency department was warranted under the circumstances.
Because the Employee’s son’s visit to the emergency department was for the appearance of acute symptoms within 48 hours, the Trustees find that the Employer is required to provide benefits for the emergency room charge resulting from the Employee’s son’s evaluation and treatment on May 6, 1991.
Opinion of the Trustees
Opinion of Trustees Resolution of Dispute Case No. 88-470
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The Employer is required to provide benefits for the emergency room charge resulting from the Employee’s son’s evaluation and treatment on May 6, 1991.