Opinion of Trustees
Resolution of Dispute
Case No. 88-415
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-415 – November 20, 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 under the terms of the Employer Benefit Plan.
Background Facts
The Employee states that he sought treatment at a hospital emergency room on Friday, August 10, 1988 for sharp chest pain that had begun while he was at work that day. The emergency room record indicates that the Employee was seen for cough, congestion and pain In the upper left chest. The Employee was given a chest x-ray. The diagnosis was bronchitis and he was given an antibiotic (Amoxicillin), advised to stop smoking, to use an over-the-counter cough syrup and to seek follow-up care for any new problems.
The Employer has denied benefits for the emergency room charges. Dispute
Is the Employer required to provide benefits for the emergency room charges resulting from the Employee’s visit on August 10, 1990?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s emergency room charges.
Opinion of Trustees Resolution of Dispute Case No. 88-415
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Position of the Employer: The Employer is not required to provide benefits for the Employee’s emergency room charges because he had been experiencing problems for a few days and did not seek emergency treatment within 48 hours of the onset of his symptoms.
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
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.
Although the Employer has claimed that the onset of the Employee’s symptoms was more than 48 hours before the emergency room visit, no evidence has been submitted to support this, and the Employee has stated that the chest pains occurred while he was at work the same day.
A Funds’ medical consultant has reviewed this case, including the emergency room report of the Employee’s visit on August 10, 1990. The consultant notes that the patient went to the emergency room from work for evaluation of chest pain, as well as cough and congestion. The consultant advises that chest pain is an acute, potentially life-threatening complaint, and should be evaluated immediately. He further notes that there is no evidence in the file that the chest pain had existed for more than 48 hours prior to the visit. The consultant therefore advises that emergency medical treatment was warranted. Inasmuch as emergency medical treatment was rendered consistent with Plan requirements, the Trustees conclude that the Employer is required to provide benefits for the Employee’s emergency room visit on August 10, 1990.
Opinion of the Trustees
The Employer is required to provide benefits under the Employer Benefit Plan for the charges resulting from the Employee’s emergency room visit on August 10, 1990.