OPINION OF TRUSTEES
ROD Case No: 88-560 – 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 November 3, 1991, the Employee’s son complained of abdominal pain. The Employee and his son agreed that the pain may have been caused by a muscle pulled during a football game at school. On Friday, November 8, 1991 the Employee’s son came home from school saying the pain had become more severe. The Employee immediately called his family physician, whose schedule was too full to examine the son. The Employee then took his son to the emergency room of the local hospital where he was evaluated and treated. The emergency room doctor, after ruling out any spleen trauma or a subcapsular hematoma of the spleen, arrived at the final diagnosis of viral infection.
The Employer rejected the charges for the emergency room and all x-ray and laboratory charges, as well as the charges for medical supplies, on the basis that the Employee did not seek treatment for his son within 48 hours of the onset of symptoms. The Employee is appealing the decision based on the fact that the symptoms did not become acute until the day he sought treatment for his son, thereby falling within the 48 hour time limitation.
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s son’s evaluation and treatment on November 8, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred by the Employee’s son on November 8, 1991 because the treatment was sought within 48 hours of the time when the symptoms became acute.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s son on November 8, 1991 because the initial onset of symptoms occurred more than 48 hours prior to the hospital visit.
The Introduction to Article III states in pertinent part:
Article III – Benefits
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 of Article III of the Employer Benefit Plan states that the Plan covers services which are rendered at the appropriate level of care. 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.
A Funds’ medical consultant has reviewed this case and has determined, from the documentation available, that the Employee’s son’s symptoms had worsened in the preceding 48 hours, thereby necessitating the emergency room visit. The consultant stated that the medical record indicates that the physical examination done by the emergency room physician was positive for significant pain in the left upper quadrant with a question of an enlarged spleen. Given the patient’s history for potential trauma from playing football, the consultant was of the opinion that the emergency room visit, laboratory work and x-rays (including the C.T. scan) are medically appropriate to evaluate the condition.
Therefore, the Employer is required to provide benefits from the Employee’s son’s emergency room visit on November 8, 1991 as it was precipitated by a worsening of the symptoms within the preceding 48 hours.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge, including all x-rays, laboratory charges and medical supplies, incurred by the Employee’s son on November 8, 1991.