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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
84-703 – February 9, 1990
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
The Employee’s spouse sought treatment at a hospital emergency room for headaches on ten occasions between February 17, 1987 and October 11, 1987. The emergency room records indicate that the patient reported symptoms of vomiting and headache on each visit, as well as blurred vision, double vision, dizziness, and nausea on some of the visits. The records also indicate that the onset of such symptoms was within 48 hours of the emergency room visit in each instance.
The diagnosis given by the emergency room physician on each of the first eight visits was migraine headache, and the treatment rendered during each of those visits was an injection of an analgesic and an agent to potentiate its effect and to reduce nausea. The diagnosis given by the emergency room physician on the last two visits was tension headache-drug addiction, and the treatment rendered in both instances was a placebo injection of normal saline solution.
The Employer denied the charges related to the use of the emergency room for all ten visits. Dispute
Is the Employer required to pay the emergency room charges resulting from the Employee’s spouse’s ten emergency room visits?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charges incurred during the ten visits because emergency medical treatment was needed,
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Position of the Employer: The Employer is not required to pay the emergency room charges incurred during the ten visits because emergency room treatment was not medically reasonable and necessary; rather, the Employee’s spouse was improperly utilizing the emergency room to supplement her drug addiction.
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. As noted in ROD 84-380 (copy enclosed herein), emergency room services are covered for the treatment of acute symptoms requiring emergency treatment, even though the underlying medical condition is chronic, The intractable pain that 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 contends that the Employee’s spouse utilized the emergency room improperly. The emergency room records for all ten visits indicate that the patient reported symptoms of vomiting and headache on each visit, as well as blurred vision, double vision, dizziness, and nausea on some of the visits. The records also indicate that the onset of such symptoms was within 48 hours of the emergency room visit in each instance. A Funds’ medical consultant has reviewed the emergency room records and advised that the frequency of the visits in this case is not excessive or unusual for a patient with recurrent migraine headaches, which require pain medication. According to the consultant, the patient reported symptoms that are consistent with those typically experienced by migraine sufferers. The diagnosis given by the emergency room physician on each of the first eight visits was migraine headache. The medical consultant advises that the treatment rendered during each visit–injection of an analgesic and an agent to potentiate its effect and to reduce nausea–is consistent with the treatment typically administered to migraine patients. The consultant is of the opinion that emergency medical treatment was rendered for an acute exacerbation (pain) of a chronic condition (migraine) on each of the first
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eight emergency room visits, inasmuch as emergency medical treatment was rendered within 48 hours of the onset of acute medical symptoms, the Trustees conclude that the Employer is required to pay the eight emergency room charges incurred from February 17, 1987 through October 3, 1987.
Although the patient reported similar symptoms on the emergency room visits of October 6, 1987 and October II, 1987, the diagnosis given by the emergency room physician on both of those visits was tension headache-drug addiction. On both occasions, the patient was given an injection of normal saline solution (a placebo). The medical consultant is therefore of the opinion that the patient did not receive emergency medical treatment for acute medical symptoms on October 6, 1987 and October 11, 1987. Accordingly, the Trustees find that the Employer is not required to pay the emergency room charges incurred on October 6, 1987 and October 11, 1987.
In ROD 81-553 (copy enclosed herein), the Trustees concluded that an 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 nor appropriate. Although this Employer has not applied such procedures, it has the right to review the appropriateness of further utilization of emergency room services before providing health benefits to the Employee’s spouse for such services in the future.
Opinion of the Trustees
The Employer is required to pay the emergency room charges resulting from the Employee’s spouse’s eight emergency room visits from February 17, 1987 through October 3, 1987. The Employer is not required to pay the emergency room charges resulting from the Employee’s spouse’s emergency room visits on October 6, 1987 and October 11, 1987.