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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-057 – December 12, 1988
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
On May 7, 1988, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room complaining of nausea and pain under both rib cages. The Employee’s spouse has indicated that her physician advised her to report to the hospital and he would call there to check on her condition. According to the emergency room record, the onset of the Employee’s spouse’s symptoms was three weeks prior to her emergency room visit.
The Employer denied charges related to the use of the emergency room stating that the onset of the Employee’s spouse’s symptoms occurred three weeks prior to the emergency room visit and there is no indication that her symptoms had become acute or had changed within the 48 hours preceding the emergency room visit.
Dispute
Is the Employer responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on May 7, 1988?
Positions of the Parties
Position of the Employee: The Employer is responsible for the payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on May 7, 1988, because the Employee’s spouse’s physician advised her to go to the emergency room.
Opinion of Trustees Resolution of Dispute Case No. 88-057 Page 2
Position of the Employer: The Employer is not responsible for payment of the emergency room charges because treatment was not rendered within 48 hours following the onset of acute medical symptoms as required under the Plan.
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, providing such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the 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.
A Funds’ medical consultant has reviewed the emergency room records pertaining to the Employee’s spouse’s evaluation and treatment on May 7, 1988. The consultant notes that the record indicates that the patient had been sick and complaining of symptoms, such as nausea and pain under both rib cages for three weeks prior to the emergency room visit. The consultant has advised that there is no evidence of acute medical symptoms that would warrant emergency medical treatment in this case. Because the emergency room care provided in this case was not prompted by acute medical symptoms that required emergency treatment, the Employer is not responsible for payment of the emergency room charges.
The dispute as filed by the Employee also mentions an excessive fee denial. The Employer states that it has implemented its hold harmless procedures in accordance with Article III. A. (10)(g) of the Employer Benefit Plan and it will attempt to resolve the matter with the provider.
Opinion of the Trustees
The Employer is not responsible for payment of the emergency room charges resulting from the Employee’s spouse’s evaluation and treatment on May 7, 1988.