_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-519 – July 15, 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 treatment under the terms of the Employer Benefit Plan.
Background Facts
On May 7, 1991, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room complaining of bilateral ear pain and a clear discharge from both ears. The nursing notes indicate she first experienced discomfort in her left ear three days earlier, but the pain in her right ear and clear fluid discharge did not begin until the morning of May 7, 1991. The emergency room physician diagnosed the condition as otitis externa (inflammation of the external ear), treated the patient and released her.
The Employer provided benefits for the services of the emergency room physician, but denied charges related to use of the emergency room.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on May 7, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on May 7, 1991 because acute medical symptoms occurred within 48 hours of the emergency room visit.
Position of the Employer: The Employer is not require,d to provide benefits for the emergency room charge resulting from the Employee s spouse’s evaluation and treatment on May 7, 1991, because Employee’s spouse did not seek treatment within 48 hours of the onset of acute medical symptoms.
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 Employer has stated that the emergency room record does not provide evidence of acute symptoms or of the discharge from the ears.
A Funds’ medical consultant has advised that the emergency room nursing notes state that the right ear hurt the day of the visit and was draining clear fluid. In the consultant’s opinion, the patient’s symptoms occurred within 48 hours of her visit, were acute in nature, and required emergency medical evaluation. Because there is evidence that the emergency room visit was prompted by acute symptoms, the Trustees conclude that the Employer is required to provide benefits for the emergency room charge resulting from the Employee’s spouse’s medical evaluation and treatment on May 7, 1991.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on May 7, 1991.