Opinion of Trustees
Resolution of Dispute
Case No. 88-548
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OPINION OF TRUSTEES _____________________________________________________________________________
In Re
Complainant: Respondent: ROD Case No:
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, 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 May 20, 1991, the Employee sought medical evaluation and treatment for back pain at the emergency department of a local medical center. The Employee stated that she had previous back problems, but that on the day in question her back had “completely locked” and she was in acute pain. The emergency room record indicates normal vital signs and pain of two weeks’ duration. The hospital advised the patient to rest, apply heat to her back, avoid heavy lifting, and continue taking the prescribed non-steroidal, anti-inflammatory and pain medications. If the condition persisted or worsened, the patient was advised to seek treatment from her personal doctor.
The Employer provided benefits for the physician charge, but denied benefits for the emergency room charge incurred on May 20, 1991.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on May 20, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred on May 20, 1991 because the symptoms became acute in the 48 hours immediately preceding the visit.
Employee
Employer
88-548 – July 15, 1992
Opinion of Trustees Resolution of Dispute Case No. 88-548
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Position of the Employer: The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on May 20, 1991 because there is no evidence that her symptoms had worsened within the last 48 hours, or that the symptoms required emergency treatment.
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.
A Funds’ medical consultant has reviewed the medical records in this case and has advised that there is no documentation in the physician notes, nursing notes or the triage notes to indicate an acute onset or exacerbation of pain within the 48 hours immediately preceding the visit and notes that the emergency room record indicates pain of two weeks’ duration. Because the use of the emergency room was for symptoms that began more than 48 hours immediately preceding the visit, the Employer is not required to provide benefits for the emergency room charge.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on May 20, 1991.