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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-533 – May 7, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Elliot A. Segal, 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 July 6, 1991, the Employee sought medical evaluation and treatment for her daughter at a hospital emergency room. The emergency room record indicates that the Employee’s daughter reported symptoms of vaginal itching, burning on urination, and vaginal discharge for a week prior to the emergency room visit. The physician diagnosed the Employee’s daughter as having a urinary tract infection and yeast vaginitis. He prescribed Monistat vaginal suppositories and Bactrim DS, and instructed the patient to see a physician as needed.
The Employer has denied payment for the charge related to the use of the emergency room on the grounds that emergency care was not necessary and was not rendered within 48 hours of the onset of an acute medical condition.
Dispute
Is the Employer required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 6, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 6, 1991 because the visit was prompted by acute medical symptoms.
Position of the Employer: The Employer is not required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 6, 1991 because the symptoms were not acute, nor was the treatment rendered within 48 hours of the onset of symptoms. Treatment could have been provided at a lower level of care with greater efficiency.
Pertinent Provisions
The Introduction to Article III states in pertinent part:
Article III – Benefit
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, or are otherwise provided for in the Plan. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan….
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
The Introduction to Article III states that the Plan covers services which are given at the appropriate level of care. 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.
The emergency room record of July 6, 1991 indicates that the Employee’s daughter had complaints of vaginal Itching, discharge and burning upon urination for a week prior to the visit. A Funds’ medical consultant has reviewed the medical record of the emergency room visit and has advised that the symptoms, as described in the record, were neither severe, acute, nor occurring within 48 hours of the visit, and, thereby, did not warrant emergency medical treatment. According to the consultant, the use of the emergency room was not medically necessary, or appropriate, for the patient’s condition. Inasmuch as there is no evidence of acute medical symptoms that would warrant emergency medical treatment, the Trustees conclude that the Employer is not required to pay the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on July 6, 1991.
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 July 6, 1991.