Opinion of Trustees
Resolution of Dispute
Case No. 88-236
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No.
In Re
Employee
Employer
88-236 – February 15, 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 health benefits for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
On April 24, 1989, the Employee’s spouse sought medical evaluation and treatment at a hospital emergency room. According to the emergency room record, the Employee’s spouse had complaints of a severe headache, numbness over her entire body, weakness, faintness and shakiness which had begun the day of the visit after she had been working all day in the sun. The emergency room physician ordered lab work and diagnosed the condition as mild heat illness/possible hypoglycemia. The Employer provided benefits for the laboratory charges, but denied the physician’s charge and the charge related to the use of the emergency room.
Dispute
Is the Employer required to pay the physician’s charge and the emergency room charge resulting from the Employee’s spouse’s emergency room visit on April 24, 1989?
Positions of the Parties
Position of the Employee: The Employer is required to pay the charges resulting from the emergency room visit on April 24, 1989, because emergency medical evaluation and treatment were necessary.
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Position of the Employer: The Employer is not required to pay the charges resulting from the emergency room visit on April 24, 1989 because the evidence does not indicate that the Employee’s spouse’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.
Article III. A. (3)(i) of the Employer Benefit Plan states: (3) Physicians’ Services and Other Primary Care
(i) Emergency Treatment
When provided by a physician, benefits are provided for a Beneficiary who receives outpatient emergency medical treatment or 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) and Article III. A. (3)(i) 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 hospital records from the emergency room visit on April 24, 1989 indicate that the Employee’s spouse had complaints of a severe occipital headache, numbness over her entire body, weakness, faintness and shakiness which had begun late that afternoon after she had been working all day in the sun. The records indicate that the emergency room physician was concerned about her symptoms and ordered lab work to check for an electrolyte imbalance and to determine her blood sugar level. A Funds’ medical consultant has reviewed the records of the emergency room visit and is of the opinion that such symptoms are acute because they can be
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indicative of hypoglycemia or heat exposure, and prompt emergency medical evaluation is warranted to prevent possible complications. Therefore, the Trustees find that the Employer is required to pay the physician’s charge and the emergency room charge’ resulting from the Employee’s spouse’s visit on April 24, 1989.
Opinion of the Trustees
The Employer is required to pay the physician’s charge and the emergency room charge resulting from the Employee’s spouse s emergency room visit on April 24, 1989.