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OPINION OF TRUSTEES _____________________________________________________________________________
Complainants: Respondent: ROD Case No:
In Re
Employee
Employer
88-471 – April 14, 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 health benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On April 21, 1991 the Employee’s spouse was taken to the outpatient emergency department of a hospital with a migraine headache. According to the emergency room record she was given intra-muscular injections of medications and released. The hospital’s examination indicated normal vital signs and normal physical findings. The spouse had been seen in the emergency room on April 13, 1991 with the same complaint. The Employer denied payment for the emergency room charges incurred on April 21, 1991.
Dispute
Is the Employer required to provide benefits for the emergency room charges resulting from the Employee’s spouse’s visit on April 21, 1991.
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charges because emergency care was medically justified and sought within 48 hours of the onset of acute medical symptoms.
Opinion of Trustees Resolution of Dispute Case No. 88-471 Page 2
Position of the Employer: The Employer is not required to provide benefits for the emergency room charges incurred on April 21, 1991 because the symptoms present on that date were the same as those on April 13, 1991, and therefore treatment was not sought within 48 hours of the onset of the symptoms. Additionally, the symptoms were not acute and, consequently, emergency care was not medically necessary.
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 any 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 or the occurrence of an accident.
A Funds’ medical consultant has reviewed this case and has concluded that the emergency room visit on April 21, 1991 was for a new migraine headache episode which had begun within the preceding 48 hours and was unrelated to the episode which precipitated the emergency room visit on April 13, 1991. He noted that it would be typical to have an examination with this condition produce normal vital signs and normal physical findings, but that this type of headache is unpredictable and severe enough to warrant emergency medical care. The consultant also made reference to a note from the patient’s neurologist requesting emergency care be given for her migraines.
Since care was rendered within 48 hours of the onset of symptoms, and the diagnosis meets the criteria for a medical emergency, the Trustees conclude that the Employer is required to pay the emergency room visit on April 21, 1991.
Opinion of the Trustees
The Employer is required to pay for the emergency room care rendered to the Employee’s spouse on April 21, 1991.