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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-813 – December 6, 1995
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and
Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On July 28, 1993, at 1:47 a.m. the Employee’s spouse sought medical evaluation and treatment in the hospital emergency room, complaining of frequent urination and back pain that had been present for two days. The emergency room nurses’ notes indicate that the patient stated that she had a history of urinary tract infections. The emergency room record further indicates that the patient’s vital signs were within normal limits.
After obtaining the results of a urinalysis, the emergency room physician diagnosed the Employee’s spouse’s condition as dysuria (painful urination), prescribed medication, advised the patient to increase fluid intake, and to follow up with her personal physician the next day, July 29, 1993.
The Employer has stated that benefits have been provided for the physician charges in connection with the visit. The Employer denied benefits for $203 for the emergency room, including $68 for the use of the emergency room, $18 for medical-surgical supplies and $117 for laboratory charges.
The Employer was signatory to the 1988 National Bituminous Coal Wage Agreement
(Wage Agreement) which terminated February 1, 1993. The Employer signed an Interim Agreement extending the terms and conditions of employment of the l988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1994.
Dispute
Is the Employer required to provide benefits for the $203 in charges connected with the emergency room visit of the Employee’s spouse on July 28, 1993?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the $203 in emergency room charges incurred by the Employee’s spouse on July 28, 1993, because her symptoms were acute, requiring emergency care.
Position of the Employer: The Employer is not required to provide benefits for the $203 in emergency room charges incurred by the Employee’s spouse on July 28, 1993, because there is no evidence that her symptoms were acute and required emergency medical treatment, and by the patient’s own admission, the symptoms had been present for two days prior to the emergency room visit.
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
The Employer was signatory to the 1988 Wage Agreement. The Employer signed an Interim Agreement extending the terms and conditions of employment of the 1988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1993. This dispute arose over an event that took place during the period covered by the Interim Agreement.
Under Article III. A. (2) (a) of the Employer Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours of the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and notes that the patient had complained of dysuria for two days prior to the emergency room visit. Additionally, the consultant advises that the medical record does not indicate any severe, or acute worsening of, the Employee’s spouse’s symptoms requiring emergency medical care. The consultant is of the opinion that the Employee’s spouse’s emergency room visit on July 28, 1993, was not medically appropriate, and that the patient could have received appropriate treatment at a lower level of care.
Because there is no evidence that new or increasingly severe acute medical symptoms occurred within 48 hours of the Employee’s spouse’s emergency room visit, the Trustees conclude that the Employer is not required to provide benefits for the $68 emergency room charge incurred on July 28, 1993, but is required to provide benefits for the $18 medical supplies and $117 laboratory charges.
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the emergency room charge incurred by the Employee’s spouse on July 28, 1993, but is required to provide benefits for the medical-surgical supplies and laboratory charges incurred on that date.