OPINION OF TRUSTEES
ROD Case No: 88-553 – 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 March 22, 1991, the Employee’s 13-year-old dependent began experiencing pain in his left knee, although he stated he did not remember a specific injury. By Sunday, March 24, 1991 the pain had worsened and the knee began to swell excessively. The Employee decided that the boy’s condition needed to be evaluated as soon as possible. Since it was Sunday and no private doctors were available, the Employee took his son to the emergency room of the local hospital for evaluation and treatment. The discharge diagnosis was “contusion, left knee”.
The Employer’s insurance company paid $102.00 of the total bill of $234.75, leaving a balance due of $132.75. The insurance company denied the $132.75 because the treatment did not qualify as a medical emergency. The amount denied included $76.75 for the use of the emergency room and $56 for the physician’s fee.
The Employee is appealing the decision and subsequent denial made by the Employer’s insurance carrier.
Is the Employer required to provide benefits for the emergency room charge and physician’s fee resulting from the Employee’s son’s evaluation and treatment on March 24, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for emergency room charge and physician’s fee resulting from the Employee’s dependent’s evaluation and treatment on March 24, 1991 because the symptoms had become acute within the preceding 24 hours, and no other doctors were available because it was a Sunday.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge and physician’s fee resulting from the Employee’s dependent’s emergency room treatment on March 24, 1991 because the condition did not qualify as a medical emergency, and the treatment was not rendered within 48 hours of the occurrence of an injury or illness.
The Introduction to Article III states in pertinent part:
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) 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.
The Introduction to Article III states that the Plan covers services which are limited to those which are medically necessary, reasonable and appropriate. Additionally, Article III. A. (2) (a) of the Employer Benefit Plan provides benefits for outpatient emergency medical treatment when it is rendered within 48 hours following an accident or the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the case and has determined that the nursing notes contained in the emergency room record indicate that the discoloration began within two days of the visit. The consultant further notes that the attending physician at the hospital also indicated a redness and discoloration in his examination of the patient. It is the consultant’s opinion that, in a 13-year-old child, not remembering an injury should not rule it out. The consultant’s opinion was that these were significant new symptoms that could lead to a more serioUs and acute process. Because the patient was seen for the acute symptoms within 48 hours of their occurrence, it is the consultant’s opinion that the emergency room charge and the physician’s fee should be considered eligible under the Employer Benefit Plan.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge and the physician’s fee incurred by the Employee’s son on March 24, 1991.