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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-130 – June 27, 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
The Employee’s six-year-old daughter was taken to a hospital emergency room on Sunday, July 3, 1988 because she had a high fever. Initially, the Employer denied the charge related to the use of the emergency room for the six-year-old child but later provided coverage for it.
The Employee’s eight-year-old daughter was also taken to the emergency room on July 3, 1988 with her six-year-old sister. According to the emergency room record, the Employee’s spouse was concerned that the eight-year-old daughter “sounds congested” and that she might develop a fever like her sister’s. The eight-year-old had an oral temperature of 98.70. She was diagnosed as having a viral syndrome and discharged with instructions to follow up with her family physician, if necessary. The Employer denied the charge related to the use of the emergency room for the Employee’s eight-year-old daughter.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s eight-year-old daughter’s evaluation and treatment on July 3, 1988?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s eight-year-old daughter’s evaluation and treatment on July 3, 1988, because emergency treatment was needed.
Position of the Employer: The Employer is not required to pay the emergency room charge because the evidence does not indicate that the Employee’s eight-year-old daughter’s medical symptoms were acute.
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.
The emergency room record indicates that the Employee’s eight-year-old daughter was afebrile. A Funds’ medical consultant has reviewed the clinical information presented in this case and has advised that there is no documentation of any symptoms or illness that would require emergency treatment. The consultant advises there is no evidence that treatment was rendered for acute medical symptoms in this instance. Because there is no evidence of the existence of acute medical symptoms, the Trustees find 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 Employee’s eight-year-old daughter’s evaluation and treatment on July 3, 1988.