Opinion of Trustees
Resolution of Dispute
Case No. 88-515
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 outpatient emergency room charges under the terms of the Employer Benefit Plan.
Background Facts
On April 24, 1991, the Employee sought medical evaluation and treatment at a hospital emergency room for his son who was suffering from swelling and redness of the left eye. The Employee has stated that his son has a medical history of allergic reactions and that his son’s physician has instructed him to seek immediate treatment, since an allergic reaction could develop into respiratory distress, which could be fatal.
The emergency room record indicates that the Employee’s son reported symptoms of redness and swelling of the left eye beginning the day of the visit. The physician diagnosed the Employee’s son as having chemosis of the left eye and a nasal allergy. He prescribed Entex and Seldane and instructed the patient to see his family physician.
The Employer has denied payment for the charge related to the use of the emergency room on the grounds that the Employee’s son’s symptoms were not acute or life threatening.
Dispute
Is the Employer required to pay the emergency room charges resulting from the Employee’s son’s evaluation and treatment on April 24, 1991?
Positions of the Parties
Employee
Employer
88-515 – May 7, 1992
Opinion of Trustees Resolution of Dispute Case No. 88-515
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Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s son’s evaluation and treatment on April 24, 1991 because the visit was prompted by acute medical symptoms.
Position of the Employer: The Employer is not required to pay the emergency room charges resulting from the Employee’s son’s evaluation and treatment on April 24, 1991 because the symptoms were not acute or life threatening and, thus, did not require emergency medical treatment. Although the Employee alleges that his son has a history of serious allergic respiratory complications which would require immediate treatment, there is no evidence of respiratory distress present on the emergency room record.
Pertinent Provisions The Introduction to Article III states in pertinent part:
ARTICLE III – BENEFITS
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.
Article III. A. (2) (a) states:
(1) Outpatient Hospital Benefits
(f) 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 record of April 24, 1991 Indicates that the Employee’s son complained of redness and swelling of the left eye beginning that day. A Fund’s medical consultant has reviewed the emergency room record and has advised that the patient who had a medical history of allergic reactions, was treated for and allergic condition of the nasal area and the left eye.
Opinion of Trustees Resolution of Dispute Case No. 88-515
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According to the consultant, even in the absence of respiratory complaints or other generalized allergic reactions, it is unreasonable to expect the patient’s father to differentiate a localized allergic reaction from a generalized systemic allergic reaction. The consultant has noted that swelling of the eye can be the first sign of a generalized allergic reaction. For that reason, the consultant has advised that, in this instance, the use of the emergency room was medically appropriate. Therefore, the Trustees conclude that the use of the emergency room in this case was justified.
Opinion of the Trustees
The Employer is required to pay the emergency room charge resulting from the Employee’s son’s evaluation and treatment on April 24, 1991.