Opinion of Trustees
Resolution of Dispute
Case No. 88-620
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OPINION OF TRUSTEES _________________________________________________________________
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In Re
Complainants: Employee
Respondent: Employer
ROD Case No: 88-620 – December 16, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; Elliott 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 charges under the terms of the Employer Benefit Plan.
Background Facts
On December 11, 1991, the Employee’s spouse took their son to the emergency room of the local hospital. The son was complainant of pain in his left leg that began three weeks earlier. The Employee states that the pain had become more severe in the preceding 24 hours and that since his wife had no medical training in order to distinguish an emergent medical condition, she took the son to the emergency room to be evaluated. The x- ray taken of the son’s left femur was negative. The diagnosis on the hospital record states, “Muscular pain left posterior thigh. Unknown Etiology.” The patient was instructed to see his personal physician for further evaluation the following week and was instructed to take Tylenol for pain.
The Employer provided benefits for the physician charge, but denied benefits for the use of the emergency room on December 11, 1991 because it was determined that emergency care was not medically appropriate and was not rendered within 48 hours of the onset of the condition. The Employee requests that the Employer reconsider the decision and provide benefits for these services.
Opinion of Trustees Resolution of Dispute Case No. 88-620
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Dispute
Is the Employer required to provide benefits for the use of the emergency room by the Employee's son on December 11, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the use of the emergency room by the Employee’s son on December 11, 1991 because the symptoms had worsened and become more severe in the preceding 24 hours.
Position of the Employer: The Employer is not required to provide payment for the Employee’s son use of the emergency room on December 11, 1991 because the pain had been present for three weeks and there is no evidence in the emergency room record that the pain worsened in the preceding 24 hours. Additionally, since the pain had been present for three weeks, the Employee could have taken his son to his personal physician for evaluation and treatment.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
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. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care.
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Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this Article III.
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
The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary, and which are given at the appropriate level of care. It continues to say that the fact that a physician prescribes a procedure or level of care does not mean that it is medically reasonable or necessary, or that it is covered under this Plan. The Introduction also states that services that are not reasonable and necessary shall include procedures which can be performed with equal efficiency at a lower level of care. Article III. A. (2)(a) 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’s son had pain in his left leg of three weeks’ duration. No mention is made in the record of an acute exacerbation occurring within the prior 48 hours, although the Employee stated such on the Request for Resolution of Dispute form. The x-rays taken at the hospital emergency room proved to be negative for breaks or fractures, and the patient was discharged with instructions to follow up with his personal physician the following week, and to take Tylenol for the pain.
A Funds’ medical consultant has reviewed the clinical information contained in this case and is of the opinion that there is insufficient documentation to establish that the onset of acute symptoms occurred within 48 hours prior to the emergency room visit. Therefore, the Employer is not required to provide
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benefits for the emergency room charge resulting from the Employee’s son’s evaluation and treatment on December 11, 1991.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s son on December 11, 1991.