Opinion of Trustees
Resolution of Dispute
Case No. 88-483
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-483 – February 25, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas N. 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 October 23, 1989, at about 10:00 am., the Employee’s 12-year-old daughter was taken to a hospital emergency room for medical evaluation and treatment. At the emergency room, the Employee’s daughter reported that she had not had a bowel movement in three days. The Employee stated in his ROD request that his daughter had been experiencing pain since October 21, 1989, and that, at the time of the emergency room visit, she was also experiencing nausea and fever. The Employee’s daughter was examined, diagnosed with constipation, treated and discharged. The Employer denied the charge related to the use of the emergency room, because the emergency treatment was not rendered within 48 hours following the onset of symptoms.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on October 23, 1989?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge.
Position of the Employer: The Employer is not required to pay the emergency room charge, because the emergency medical treatment was not rendered within 48 hours following the onset of symptoms.
Opinion of Trustees Resolution of Dispute Case No. 88-483
Page 2
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 Employer denied the emergency room charge in question, stating that the treatment was not rendered within 48 hours following the onset of symptoms. A Funds’ medical consultant has reviewed the records of the emergency room visit and has advised that the onset of the patient’s symptoms of constipation may have occurred within 48 hours of the emergency room visit. However, the consultant also states that the symptoms, their severity, and their duration were not documented in the medical record. Because there is no medical evidence to support the existence of acute medical symptoms, the medical consultant’s opinion is that the emergency medical treatment at an emergency room was not medically necessary. The Trustees conclude that the Employer is not required to pay the emergency room charge because there was no evidence in the medical records that the patient was experiencing acute medical symptoms.
Opinion of the Trustees
The Employer is not required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on October 23, 1989.