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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-532 – July 29, 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 Monday, March 11, 1991, the Employee sought medical evaluation and treatment at a hospital emergency room. He had sought treatment from his physician, whose schedule was full, and he was referred to the emergency room by the doctor’s office staff. The emergency room record indicates that the Employee reported symptoms of sore throat, fever, chills, and congestion that had begun the previous Friday night. The emergency room physician diagnosed the condition as bronchitis, treated, and released the patient.
The Employer provided benefits for the physician’s charge under the Employer Benefit Plan, but denied charges for use of the emergency room, stating that the Employee’s condition did not constitute a medical emergency.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on March 11, 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 evaluation and treatment on March 11, 1991 because his own physician was unable to see him that day and the personnel in the physician’s office had advised him to go to the emergency room.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge because the Employee did not suffer from acute symptoms whose onset were within the previous 48 hours, and therefore, did not warrant emergency treatment.
Pertinent Provisions
Article III. A. (2)(a) of the Employer Benefit Plan states:
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accidental 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 or the occurrence of an accident.
The emergency room record indicates that the Employee sought treatment at 9:40 A.M. on Monday, March 11, 1991 for symptoms that were first experienced the previous Friday night, March 8, 1991. The Employee states that he attempted to seek treatment from his own physician, but the physician’s schedule was full and the office personnel advised him to go to the emergency room.
A Funds’ medical consultant has reviewed the clinical information in this case. He advised that since the symptoms initially occurred more than 48 hours prior to the emergency room visit and there is no documentation in the record of new symptoms or physical findings have occurred within 48 hours of the visit, it is his opinion that the charge for the emergency room on March 11, 1991 should not be covered by the Employer Benefit Plan. However, the charges for the x-ray and laboratory studies would be eligible under the Plan as they were diagnostic in nature and would have been necessary for the treatment of the condition regardless of the setting. The fact that the doctor’s office staff referred him to the hospital does not override the requirements of the Plan in this instance.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on March 11, 1991. The Employer is, however, required to provide benefits for the x-ray and laboratory charges totalling $109.00.