OPINION OF TRUSTEES
ROD Case No: 88-550 – 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 care under the terms of the Employer Benefit Plan.
On July 16, 1991, the Employee sought medical evaluation and treatment for a severe earache at the emergency department of a medical center. The emergency room record indicates that the patient complained of ear and head pain of three to four hours’ duration. The emergency room physician diagnosed otitis media and externa (inflammation of the middle and external ear), gave the patient a dosage of antibiotics in the emergency room, and prescribed amoxil and ear drops for home use.
The Employer provided benefits for the charge for the emergency room physician’s charge, but denied benefits for the emergency room charge.
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s treatment on July 16, 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 July 16, 1991 because treatment was rendered within 48 hours of the onset of acute medical symptoms.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s emergency room charge because the symptoms were not acute and the treatment rendered was not of an emergency nature.
Article III. A. (2) (a) of the Employer Benefit Plan provides:
(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.
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.
A Funds’ medical consultant has reviewed this file and determined that the Employee’s emergency room visit on July 16, 1991 would be considered medically appropriate due to the acute medical symptoms present and because the emergency room care was sought within 48 hours of the onset of the acute symptoms. Additionally, the consultant notes that the symptoms were of enough concern to warrant the physician administering a dosage of antibiotics in the emergency room as well as prescribing an antibiotic and ear drops for home use. Furthermore, the consultant states that the patient was diagnosed as having both otitis media and externa, both of which can cause severe pain and headaches; besides the severe pain, otitis media can lead to a more serious infection, perforation of the tympanic membrane and/or a loss of hearing. In the consultant’s opinion, this was an emergent condition requiring treatment as soon as the symptoms became present, and, therefore, should be covered by the Employer Benefit Plan.
The Employer has also noted that the emergency room record classified the case as “Non Urgent”. The Funds’ medical consultant advises that the emergency department’s classifications of non urgent, urgent and emergent for coverage review have no relevance. The consultant further states these are classifications used by the hospital staff to determine whether the patient needs care immediately, within several minutes, or may wait up to an hour or more, if necessary; they are in no way meant to evaluate the patient’s need for same day emergency care.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge incurred by the Employee on July 16, 1991.