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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 Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, Trustee.
Pursuant to Article SR 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 August 2, 1987, the Employee’s nineteen-year-old daughter sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, the Employee’s daughter complained of pain from her mouth to her right ear that had begun on July 30, 1987. The emergency room physician diagnosed the Employee’s daughter’s condition as otitis externa and otitis media (inflammation of both the external and middle earl and discharged her with prescriptions for ear drops, oral antibiotics, and pain medication.
On October 18, 1987, the Employee’s seven-year-old son, who is asthmatic, was taken to a hospital emergency room for medical evaluation and treatment. According to the hospital’s emergency room record, the Employee’s son complained of a slight fever, a sore throat, and a croupy cough that had begun the previous day. The emergency room physician diagnosed the Employee’s son’s condition as acute bronchitis and discharged him with prescriptions for an oral antibiotic and decongestant cough medicine.
On December 6, 1987, the Employee’s seven-year-old son was again taken to the emergency room for medical evaluation and treatment. According to the hospital’s emergency room record, the Employee’s son had complaints of cold symptoms, congestion, coughing, an irritated throat, and wheezing. The record does not indicate the duration of the child’s symptoms prior to the emergency room visit on December 6, 1987. The emergency room physician diagnosed the Employee’s son’s condition as acute bronchitis/upper respiratory infection and discharged him with prescriptions for an oral antibiotic and decongestant cough medicine.
The Employer denied the charges related to the use of the emergency room for all three visits. Initially, the Employer had also denied charges related to five other emergency room visits made by the Employee’s dependents. The disputes concerning those charges were later resolved.
Employee
Employer
84-696 – June 7, 1989
Opinion of Trustees Resolution of Dispute Case No. 84-696 Page 2
Dispute
Is the Employer required to pay the emergency room charges resulting from the Employee’s daughter’s emergency room visit on August 2, 1987 and the Employee’s son’s emergency room visits on October 18, 1987 and December 6, 1987?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charges for all three visits because the services were rendered within the guidelines for coverage under the Employer Benefit Plan.
Position of the Employer: The Employer is not required to pay the emergency room charges for the Employee’s daughter’s visit on August 2, 1987 because medical treatment was not rendered within 48 hours of the onset of her symptoms.
The Employer is not required to pay the emergency room charges for the Employee’s son’s visits on October 18, 1987 and December 6, 1987 because he did not exhibit acute symptoms that required emergency medical treatment on either of those visits.
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
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 following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the clinical information pertaining to all three emergency room visits in question. The August 2, 1987 emergency room record indicates that the Employee’s daughter had complaints of ear and face pain which had begun three to four days prior to her visit to the emergency room. The consultant advises that the patient was afebrile and that her condition was not described in the hospital’s emergency room record as being emergent
Opinion of Trustees Resolution of Dispute Case No. 84-696 Page 3
or critical at the time of the emergency room visit. The consultant is of the opinion that the medical treatment provided on August 2, 1987 was not rendered for acute medical symptoms. Accordingly, the Trustees find that the Employer is not required to pay the emergency room charges for the Employee’s daughter’s emergency room visit on August 2. 1987.
The October 18, 1987 emergency room record indicates that the Employee’s seven-year-old son, who is asthmatic, had complaints of sore throat, croupy cough, and fever that had begum the day before the emergency room visit. The emergency room physician’s examination revealed that the child had rhonchi (sonorous chest sounds) and an increased respiratory rate. The consultant advises that the child’s wheezing warranted emergency medical treatment, and such treatment was provided within 48 hours of the onset of the child’s acute symptoms. Accordingly, the Trustees find that the Employer is required to pay the emergency room charge incurred on October 18, 1987.
The December 6, 1987 emergency room record indicates that the Employee’s seven-year-old son had complaints of cold symptoms, congestion, coughing and wheezing. There is no indication of the duration of the symptoms; however, the consultant advises that, given the patient’s asthma history and rapid respiratory rate, such symptoms would reasonably indicate the need for emergency medical care. The consultant is of the opinion that, given the patient’s acute medical symptoms, emergency medical treatment was warranted and provided on December 6, 1987. Accordingly, the Trustees find that the Employer is required to pay the emergency room charge incurred on December 6, 1987.
Opinion of the Trustees
The Employer is not required to pay the emergency room charge resulting from the Employee’s daughter’s emergency room visit on August 2, 1987. The Employer is required to pay the emergency room charges resulting from the Employee’s son’s emergency room visits on October 18, 1981 and December 6, 1987.