Opinion of Trustees
Resolution of Dispute
Case No. 84-555
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OPINION OF TRUSTEES ______________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
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
The Employee’s dependent son sought medical evaluation and treatment at a hospital emergency room at 1:23 a.m. on June 16, 1987. According to the hospital’s emergency room record, the Employee’s son was experiencing sharp chest pains, a throbbing headache, pain in the knees and back, chills and a fever. The Employee’s son was diagnosed as having a viral infection. The Employer paid the physician’s charge for evaluation and treatment and the hospital charges for the tests performed and medication dispensed at the hospital. It denied charges related to the use of the emergency room on the basis that it has no record from the hospital that emergency medical treatment was rendered or that there was an onset of acute medical symptoms as required under the Employer Benefit Plan.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on June 16, 1987?
Positions of the Parties
Position of the Employee: The Employer is responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on June 16, 1987 because treatment was sought within 48 hours of the onset of acute medical symptoms.
Pensioner
Employer
84-555 – April 7, 1988
Opinion of Trustees Resolution of Dispute Case No. 84-555
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Position of the Employer: The Employer is not responsible for the Employee’s son’s emergency room charges because the patient’s medical symptoms were not acute and no emergency medical treatment was rendered.
Pertinent Provisions Article III. A. (2)(a) of the Employer Benefit Plan provides:
(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 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 onset of the Employee’s son’s medical symptoms occurred during the evening prior to the emergency room visit at 1:23 a.m., on June 16, 1987. The emergency room record also indicates that the Employee’s son was experiencing sharp chest pains and a throbbing headache, among other complaints. The Employee’s son’s condition prompted the emergency room physician to order a battery of tests, which included an electrocardiogram and the placement of a cardiac monitor.
A Funds’ medical consultant has advised that the Employee’s son’s symptoms were acute and required emergency medical treatment, which was provided by the emergency room physician. Inasmuch as the Employee’s son received emergency medical treatment within 48 hours following the onset of acute medical symptoms, the Employer is responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on June 16, 1987.
Opinion of the Trustees
The Employer is responsible for payment of the emergency room charges resulting from the Employee’s son’s evaluation and treatment on June 16, 1987.