Opinion of Trustees
Resolution of Dispute
Case No. 88-409
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-409 – August 13, 1991
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 for an Employee under the terms of the Employer Benefit Plan.
Background Facts
On the afternoon of Saturday, February 2, 1991, the Employee sought medical evaluation and treatment at a hospital emergency room for a toothache that had begun six hours prior to the emergency room visit. The employee states that he sought emergency medical attention because no dentist was available. According to the Employee, the same tooth had been infected one month prior to the emergency room visit and he had been treated with antibiotics at that time. On February 2, 1991, the emergency room physician noted that the Employee’s face was swollen and his gum was swollen, tender and red. The physician diagnosed the Employee as having an abscessed tooth and prescribed an antibiotic for the infection and pain relief medication. He instructed the Employee to apply heat and to see his dentist on Monday.
The Employer denied benefits under the Employer Benefit Plan for the physician’s charge and the charge related to the use of the emergency room on the grounds that the visit was for dental services that are not covered under the medical Plan. The Employer processed the claim under its Dental Plan and applied the maximum benefit ($15.20) payable for a hospital call to the Employee’s annual deductible under the Dental Plan.
Dispute
Is the Employer required to provide benefits under the Employer Benefit Plan for the physician’s charge and the emergency room charge resulting from the Employee’s evaluation and treatment on February 2, 1991?
Opinion of Trustees Resolution of Dispute Case No. 88-409
Page 2
Positions of the Parties
Position of the Employee: The Employer is required to pay the charges resulting from the emergency room visit on February 2, 1991 because the Employee’s tooth had become infected and no dentist was available at that time for treatment.
Position of the Employer: The Employer is not required to pay the charges resulting from the emergency room visit on February 2, 1991 because the visit was for dental services which, with certain exceptions not relevant in this case, are specifically excluded from coverage under the Employer Benefit Plan.
Pertinent Provisions 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.
Article III. A. (3)(i) of the Employer Benefit Plan provides: (3) Physician’s 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
The Employer denied the physician’s charge and the emergency room charge in question, stating that dental services in a hospital emergency room are not covered under the Employer Benefit Plan, except under the conditions noted in Article III. A. (1)(g), Article III. A. (3)(e) and Q&A
Opinion of Trustees Resolution of Dispute Case No. 88-409
Page 3
81-16. However, the provisions cited by the Employer pertain to benefits for inpatient hospitalization for certain dental and oral surgical procedures and are not applicable to emergency medical care.
The Employer has also cited several RODs in support of its position; however, each of the RODs cited pertains to coverage for oral surgery performed in a hospital and is not relevant to the issue in this case. This case is similar to ROD 84-713 (copy enclosed herein) in which the Trustees decided whether an emergency room visit for treatment of pain that resulted from dental work is covered under the Plan provision which governs benefits for emergency room use. As in that case, the dispute here is not whether dental work is covered under the Plan; the issue is whether the charges resulting from the emergency room visit on February 2, 1991 are covered under the Plan.
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 February 2, 1991 indicate that the Employee was treated for complaints of a toothache that had begun earlier that day and that he was instructed to see his dentist on the following Monday. A Funds’ medical consultant has reviewed the records of the emergency room visit and has advised that it would not have been obvious to the patient whether his symptoms represented soft tissue Infection or an abscess of a tooth. The consultant noted that many dental and periodontal infections are appropriately treated by medical facilities. The consultant has advised that the patient’s symptoms were severe enough to warrant emergency medical evaluation and treatment, and emergency medical care for pain and infection was appropriate in this instance. Inasmuch as the Employee’s symptoms were acute and warranted emergency medical treatment, the Trustees conclude that the Employer is required to provide benefits under the Employer Benefit Plan for the physician’s charge and the emergency room charge for the visit on February 2, 1991.
Opinion of the Trustees
The Employer is required to provide benefits under the Employer Benefit Plan for the physician’s charge and the emergency room charge resulting from the Employee’s emergency room visit on February 2, 1991.