______________________________________________________________________________
OPINION OF TRUSTEES
______________________________________________________________________________
In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 84-494 – December 2, 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 benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On July 1, 1986, the Employee’s nineteen-year-old son sought treatment in the emergency room of a local hospital. The Employee claims that his son had poison ivy in his eyes. The emergency room record indicates that the Employee’s son presented with complaints of poison ivy on his arms and his face “for the last couple of days.” The physician noted a fine rash on his neck and his forearm; no other lesions were noted. The Employer’s son was discharged with instructions to take oral steroid medication and to seek follow-up treatment if the condition did not improve.
The Employer paid the physician’s charges for this service but denied the emergency room charges because the Employee’s son’s symptoms were not acute and did not warrant emergency medical treatment.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s son’s visit on July 1, 1986?
Positions of the Parties
Position of the Employee: The Employer is responsible for the payment of the emergency room charge resulting from the Employee’s son’s visit on July 1, 1986.
Position of the Employer: The Employer is not responsible for the payment of the emergency room charge resulting from the Employee’s son’s visit on July 1, 1986 because his symptoms were not acute and did not warrant emergency medical treatment.
Pertinent Provisions
Article III. A. (2)(a) of the Employer Benefit Plan provides:
(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 an 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’s son had a rash on his neck and his forearm. There is no documentation by the emergency room staff that the poison ivy affected the Employee’s son’s eyes. The Fund’s medical consultant has advised that there is insufficient evidence to conclude that the Employee’s son’s condition was severe enough to necessitate emergency room treatment. Because there is insufficient evidence of acute medical symptoms which would warrant emergency room treatment, the Employer is not responsible for payment of the emergency room charge.
Opinion of the Trustees
The Employer is not responsible for the payment of the emergency room charge resulting from the Employee’s son’s visit on July 1, 1986.