Opinion of Trustees
Resolution of Dispute
Case No. 88-487
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-487 – 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 Stated Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning provision of benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On July 13, 1991, the Employee sought medical evaluation and treatment for his 11-month-old daughter at a hospital emergency room. The child had a 103 degree fever and the emergency room physician diagnosed otitis media and prescribed Ceclor to treat the infection and Tylenol for symptomatic relief. The emergency room visit was considered a medical emergency, and the charged for this visit were paid by the Employer.
On July 16, 1991, the Employee again sought medical evaluation and treatment for his daughter at the hospital emergency room. The emergency room records indicate that a rash had developed on the patient’s body. The emergency room records indicate a temperature of 97.9 degrees. The emergency room physician’s report states that the patient’s rash could have been an allergic reaction, although it looked more like a roseola rash. The physician noted that the child’s ear drum was still red. The physician changed the prescribed medications from Ceclor and Tylenol to Septra and PediaProfen.
The Employer denied the emergency room charge for the July 16, 1991 visit on the grounds the Employee’s daughter’s condition did not require emergency medical treatment.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 16, 1991?
Position of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-487
Page 2
Position of the Employee: The Employer is required to pay the emergency room charge incurred on July 16, 1991 because emergency treatment was necessary.
Position of the Employer: the Employer is not required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 16, 1991 because there is no evidence that her symptoms had worsened or required emergency medical 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
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.
The emergency room records indicates that the Employee’s daughter was being treated with the antibiotic Ceclor for otitis media and that she had developed a rash on her body prior to the July 16, 1991 emergency room visit.
A Funds’ medical consultant has reviewed the medical records in this case and has advised that the rash developed by the patient could have been viral in nature, or indicative of the progression of an allergic reaction, a bacterial infection, or an ideopathic condition. The consultant is of the opinion that the rash needed to be evaluated that day, as it was a new physical finding of less than 48 hours duration. According to the records, the physician finding of the patient felt that the rash could possibly have been caused by the Ceclor, so he discontinued that medication and started the patient on another antibiotic. For these reasons, the medical consultant has advised that the visit of July 16, 1991 was warranted for evaluation and treatment of new symptoms that were reasonably judged to be acute.
Opinion of the Trustees
The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 16, 1991.