Opinion of Trustees
Resolution of Dispute
Case No. 84-380
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-380 – December 7, 1987
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William B. Jordan, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., 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 health benefits coverage for hospital emergency room services received by the Employee.
Background Facts
The Employee experiences recurrent severe migraine headaches which often require injections of pain medication.for relief. His physician has instructed him to go to the local emergency room when the headaches occur after office hours and are not relieved by oral medication.
According to records available to the Employer, during the period from July 25, 1985 through January 21, 1986, the Employee was treated for headache pain twenty-six times in an emergency room and six times in the physician’s office. The Employer has paid for all of the charges associated with these services except six $30.00 emergency room charges. The Employer denied those charges on the basis that the services were being used to treat a chronic medical problem rather than a medical emergency. It also determined that the number of emergency room visits was excessive and constituted inappropriate and medically unnecessary utilization of those services.
Dispute
Is the Employer responsible for payment of the charges for the Employee’s six emergency room visits?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the charges for the six emergency room visits.
Opinion of Trustees Resolution of Dispute Case No. 84-380
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Position of the Employer: The Employer is not responsible for payment of the charges for the six emergency room visits because the number of visits is excessive and constitutes inappropriate and medically unnecessary utilization of services. The emergency room services were being used to treat a chronic medical problem rather than a medical emergency.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states in part:
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.
1981 Contract Q&A #81-10 states:
Subject: Definition of Emergency Treatment Benefit
References:Amended 1950 and 1974 Benefit Plans & Trusts, Article III, Sections A (2) (a) and A (3) (i)
Question:
Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
- Would emergency treatment for conditions such as the following be covered under this provision:
- – acute pain attributed to gout?
- – heart attack, severe chest pain, or congestive failure experienced by a patient with (chronic) heart disease?
- – intracranial bleeding or stroke experienced by a patient with hypertension?
- Are benefits provided for inpatient and outpatient hospital and physicians’ services following emergency treatment beyond the 48-hour initial care limit (for example, suture removal or cast removal)?
Answer:
Opinion of Trustees Resolution of Dispute Case No. 84-380
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- Yes, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic.
- Yes, if the follow-up treatment is covered under the Plan.
1981 Contract Q&A #81-85 states:
Subject: Follow-up Care to Emergency Treatment
References:Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Sections A (2) (a) and (3) (i)
Question:
- A beneficiary requires follow-up services to emergency treatment which are rendered beyond the 48-hour initial emergency care limitation, and which are also rendered in an emergency room. Are benefits provided for both the medical treatment and the emergency room charges?
- A beneficiary requires emergency room treatment and receives it within 48 hours of the onset of acute symptoms. After the 48-hour period has expired the acute symptoms reappear. If the beneficiary goes to the emergency room for treatment within 48 hours of the reappearance of the acute symptoms, are benefits provided for both the medical treatment and the emergency room charges?
Answer:
- In this situation, the charge for emergency room service is not covered. However, benefits will be provided for charges for medical treatment which is otherwise covered under the Plan.
- YesDiscussion
The Employer denied benefits in this case for three reasons: (1) the emergency room services were for treatment of a chronic medical problem, (2) the number of emergency room visits was excessive and constituted inappropriate utilization of those services, and (3) the services constituted medically unnecessary treatment.
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The first reason is directly addressed by Q&A #81-10 and Q&A #81-85. Under Q&A #81-10, emergency room services are covered for the treatment of acute symptoms requiring emergency treatment, even though the underlying medical condition is chronic. Under Q&A #81-85, emergency room services are covered for the treatment of such recurring acute symptoms. The intractable pain which usually accompanies chronic migraine headaches is an example of a recurring acute symptom associated with a chronic medical condition. Therefore, emergency room treatment for migraine headaches is a covered benefit.
The Employer also denied the charges on the basis that the emergency room treatment was neither medically necessary nor appropriate and the number of visits was excessive. A Funds’ physician consultant has reviewed this case and is of the opinion that the Employee’s symptoms were an acute exacerbation of a chronic medical condition. Therefore, the charges for the six emergency room visits in question are covered under the Employer Benefit Plan.
In ROD 81-553 (copy enclosed herein) the Trustees concluded that the Employer, by virtue of having obtained an independent opinion from a consulting physician and a peer review organization, had applied reasonable procedures to establish that the services in question were neither medically necessary non appropriate. Thus, the Employer has the right to review the appropriateness of further utilization of emergency room services before providing health benefits to the Employee for such services in the future.
Opinion of the Trustees
The Employer is responsible for the payment of benefits for the six hospital emergency room visits.