Opinion of Trustees
Resolution of Dispute
Case No. 88-554
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; 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 June 1, 1991, the Employee sought medical evaluation and treatment for nausea, vomiting, and diarrhea at a hospital emergency room. The emergency record indicates that the patient also complained of dull aches, dizziness, and cramps. The emergency room physician diagnosed viral gastroenteritis and released the patient with orders to rest, take fluids, and observe a bland diet.
The employer denied benefits for the emergency room charge. Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s treatment on June 1, 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 June 1, 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 Employee’s symptoms were not acute and the treatment rendered was not of an emergency nature.
Employee
Employer
88-554 – July 29, 1992
Opinion of Trustees Resolution of Dispute Case No. 88-554
Page 2
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 or the occurrence of an accident.
A Funds’ medical consultant has reviewed this file and determined that the Employee’s emergency room visit on June 1, 1991 should be considered medically appropriate because the Employee’s history, as recorded by the emergency room doctor and the nurse, was consistent with the diagnosis of viral gastroenteritis, which can cause acute symptoms.
In denying benefits, the Employer stated that the emergency room classified the Employee’s condition as “good” on the emergency room record, and that there were normal temperature readings and no evidence of acute symptoms. The Funds’ medical consultant has advised in previous opinions that the emergency room’s classification of good, fair, or poor condition has no relevance for coverage determination. 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. The classifications are in no way meant to evaluate the patient’s need for same day emergency care. Further, the consultant states that patients with viral gastroenteritis typically have normal vital signs and appear normal upon physical examination. These findings would not preclude the necessity of an emergency room visit.
Therefore, it is the opinion of the Trustees that the Employee’s emergency room visit on June 1, 1991 was medically appropriate.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge incurred by the Employee on June 1, 1991.