Opinion of Trustees
Resolution of Dispute
Case No. 84-714
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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 are under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s sixteen-year old daughter was taken to a hospital emergency room on June 2, 1987. According to the emergency room record, she had been swimming in a lake during the week prior to the emergency room visit and complained of redness and irritation of the left eye which had begun the day before the visit. The Employee’s daughter was diagnosed as having conjunctivitis and was instructed to use an antibiotic ointment for three days. The Employer denied the charge related to the use of the emergency room.
Dispute
Is the employer required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation treatment on June 21, 1987?
Position of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on June 21, 1987 because she was treated within 48 hours of the onset of of an acute illness.
Employee
Employer
84-714 – May 24, 1990
Opinion of Trustees Resolution of Dispute Case No. 84-714
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position of the Employer: The Employer is not required to pay the emergency room charge because redness of the eyes is not an acute medical symptom requiring emergency medical treatment.
Pertinent Provision 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
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 or the occurrence of an accident.
The hospital records from the emergency room visit on June 21, 1987 indicate that the patient had been swimming in a lake during the week prior to the visit and complained of redness and irritation of the left eye which had begun the day before and had worsened the day of the emergency room visit. A Funds’ medical consultant has reviewed the information submitted in this file and has advised that given such symptoms, the patient and her family would not have known whether she was suffering from an iritis (an inflammation of the iris of the eye), which could lead to serious complications such as glaucoma or blindness if not treated promptly, or from ordinary conjunctivitis. The medical consultant is of the opinion that the emergency room visit in this case was prompted by the onset of symptoms that are reasonably judged to be acute, and emergency medical treatment was warranted in this case. Because the Employee’s daughter had developed acute medical symptoms that required emergency medical evaluation within 48 hours of the emergency room visit, the Trustees conclude that the Employer is required to pay the emergency room charge.
Opinion of the Trustees
The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on June 21, 1987.