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OPINION OF TRUSTEES
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In Re
Complainant: Pensioner
Respondent: Employer
ROD Case No: 88-112 – August 2, 1989
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 November 21, 1988, the Pensioner’s spouse sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, she complained of left lower back pain radiating to her left thigh. Although the emergency room record does not indicate the onset or duration of the symptoms, it categorizes her condition on arrival as “non-urgent” and states that her pain was “not severe.” The Pensioner’s spouse was diagnosed with sciatica (lower back pain), given medication, and discharged.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Pensioner’s spouse’s evaluation and treatment on November 21, 1988?
Positions of the Parties
Position of the Pensioner: The Employer is required to pay the emergency room charge because emergency treatment was medically necessary. The Pensioner also states that he took his wife to the emergency room because she had begun to have chest pains.
Position of the Employer: The Employer is not required to pay the emergency room charge because the Pensioner’s spouse did not exhibit acute medical symptoms requiring emergency medical treatment.
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. Although the Pensioner states that his spouse visited the emergency room because of chest pains, the emergency room record indicates that the Pensioner’s spouse complained only of lower back pain radiating into her left leg. There is no reference to chest pain in the emergency room record.
A Funds’ medical consultant has reviewed the clinical information presented in this case and advised that both the physician’s notes and the nursing assessment indicate that the patient complained of back pain radiating into her left leg. The consultant advised that he finds no evidence that the back pain was severe or that there were any acute medical symptoms that would warrant emergency medical treatment in this case. He also advised that he finds no indication that the emergency room physician was concerned about the Pensioner’s spouse’s cardiac status; the physician did not order an EKG (electrocardiogram) or chest x-ray to monitor for cardiac distress. Because there is no evidence of acute medical symptoms, the Employer is not required to pay the emergency room charge.
Opinion of the Trustees
The Employer is not required to pay the emergency room charge resulting from the Pensioner’s spouse’s evaluation and treatment on November 21, 1988.