Opinion of Trustees
Resolution of Dispute
Case No. 84-699
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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 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 August 7, 1987, the Employee sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, the Employee complained of severe stomach pain and nausea which had begun within the previous 24 hours. The Employee has a history of ulcer disease, and the emergency room physician diagnosed her condition as peptic ulcer disease. The Employer has denied coverage for the Employee’s August 7, 1987 emergency room treatment.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on August 7, 1987?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on August 7, 1987 because she needed emergency medical treatment and she sought treatment within 24 hours of the onset of her symptoms.
Employee
Employer
84-699 – May 30, 1989
Opinion of Trustees Resolution of Dispute Case No. 84-699
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Position of the Employer: The Employer is not required to pay the emergency room charge because emergency medical treatment was an inappropriate level of care which resulted from the Employee’s refusal to follow previously given medical advice and to properly take prescription medication.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan states:
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.
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 the accident.
Discussion
The introduction to Article III of the Employer Benefit Plan states that 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. The Employer contends that the emergency room care received by the Employee was an inappropriate level of care which resulted from the Employee’s refusal to follow previously given medical advice and to properly take prescription medication for her ulcer. However, whether emergency room treatment is appropriate and covered under the Plan is determined according to Article III. A. (2)(a) of the Plan.
Article III. A. (2)(a) provides that emergency room treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms. The Employer does not contend that the Employee failed to satisfy the criteria of Article III. A. (2)(a). A Funds’ medical consultant has reviewed the information pertaining to the Employee’s emergency room visit and advised that the visit was prompted by the onset of severe abdominal pain, an acute symptom, which had begun within the previous 24 hours. The consultant stated that, in his opinion, emergency medical treatment was warranted to rule out biliary disease. Accordingly, the Trustees find that the Employer is required to pay the emergency room charge resulting from the Employee’s treatment on August 7, 1987.
Opinion of Trustees Resolution of Dispute Case No. 84-699
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Opinion of the Trustees
The Employer is required to pay the emergency room charge resulting from the Employee’s evaluation and treatment on August 7, 1987.