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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees:
In Re
Pensioner
Employer
CA-045 – July 18, 2001
A. Frank Dunham, Michael H. Holland, Marty D. Hudson and Elliot A. Segal.
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 Coal Industry Retiree Health Benefit Act of 1992 (Coal Act) Employer Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.
Background Facts
The Pensioner’s spouse had itching for several days and had made an appointment to see her physician at 1:00 p.m. on April 15, 1998. However, just after midnight on April 15, 1998, she awoke with hives all over her body. She took Benadryl without relief and went to the emergency room at 2:00 a.m. In addition to the itching, she had vomiting and diarrhea during the day prior to being seen in the emergency room. After being treated, she was advised to keep her scheduled appointment with her regular physician.
The Employer provided benefits coverage for the Pensioner’s spouse’s evaluation and treatment but denied the emergency room charge incurred on April 15,1998.
Dispute
Is the Employer required to provide benefits for the Pensioner’s spouse’s emergency room charge incurred on April 15, 1998?
Positions of the Parties
Position of the Pensioner: The Employer is required to provide benefits for the Pensioner’s spouse’s emergency room charge because it was medically necessary.
Position of the Employer: The Employer is not required to provide benefits for the Pensioner’s spouse’s emergency room charge because more than 48 hours had elapsed and the symptoms did not warrant emergency medical care.
Opinion of Trustees ROD Case No. CA-045 Page 2
Pertinent Provisions Article III A. (2) (a) of the 1993 Employer Benefit Plan states:
ARTICLE III BENEFITS
A. Health Benefits
(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.
A Funds’ medical consultant has reviewed the documentation submitted in this case and has concluded that symptoms of hives, vomiting and diarrhea occurred within 48 hours prior to treatment and are symptoms that could lead to serious medical consequences if not treated. He noted that the itching, while present off and on for three days, clearly was not the reason for the emergency visit and that her emergency room treatment was appropriate. Therefore, the Trustees conclude that the Employer is required to provide coverage for the emergency room charge.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge resulting from the Pensioner’s spouse’s evaluation and treatment on April 15, 1998.