_____________________________________________________________________________
OPINION OF TRUSTEES
_____________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-603 – September 21, 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 Wednesday, January 22, 1992 at 12:40 pm., the Employee sought medical evaluation and treatment at a hospital emergency room, complaining of sore throat, difficulty talking and aching all over. The emergency room physician diagnosed laryngitis and otitis media, and treated and released the patient.
The Employer provided benefits for the physician charges, but denied payment for the emergency room charge incurred on January 22, 1992.
Dispute
Is the Employer required to provide benefits for the emergency room room charge resulting from the Employee’s evaluation and treatment on January 22, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge because of the seriousness of the illness.
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment because the Employee’s condition did not warrant emergency medical treatment; he could have been treated by a private physician.
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.
The emergency room record indicates that the Employee had symptoms of sore throat, difficulty talking, and achiness that had begun the day before. A Funds’ medical consultant has reviewed the information present in this case and has advised that the patient’s symptoms were not of such severity as to warrant an emergency room visit in the middle of the day rather than a visit to his doctor’s office or a clinic. The Trustees, therefore, conclude that the Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment of January 22, 1992.
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 January 22, 1992.