Opinion of Trustees
Resolution of Dispute
Case No. 88-595
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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-595 – September 21, 1992
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 December 31, 1991, the Employee began to have pain in his shoulder. He attempted to make an appointment with his physician, but was not successful. The next day, January 1, 1992, was a holiday and the Employee’s physician was unavailable. On January 2, 1992 the Employee met his physician at a medical center emergency room where that same physician was on duty. The physician injected the patient’s shoulder with Depo-Medrol and placed him on Lodine.
The Employer provided benefits for the physician charge, but denied payment for the emergency room charge incurred on January 2, 1992.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on January 2, 1992?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred on January 2, 1992 because there were acute symptoms that had appeared within 48 hours of the emergency room visit.
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 January 2, 1992 because the Employee’s symptoms were not acute and did not require emergency treatment.
Opinion of Trustees Resolution of Dispute Case No. 88-595
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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. The consultant notes that the patient was having increasing pain from bursitis in the left shoulder, which was treated with a steroid injection and medication by mouth, thus indicating the severity of the bursitis. Furthermore, the consultant states that, although the medical chart records that the pain had been present for three to four days and was listed as a dull ache at that time, as is usually the case with bursitis, the pain increases over time in a crescendo fashion with the more severe pain having been present for less than 48 hours.
It is the opinion of the consultant that the Employee’s emergency room visit on January 2, 1992 was appropriate because of the increasing pain that was present 48 hours prior to the visit, and the holidays prevented the patient from seeing his physician in the office.
The Employer also notes that-he emergency room record classified the case as “non-emergent”. The Funds’ medical consultant has advised in prior cases that the emergency department’s classifications of emergent or non-emergent for coverage review have no relevance. These are classifications used by the hospital staff to determine whether the patient needs care immediately, within several minutes, or may wait up to an hour or more, if necessary; they are not meant to evaluate the patient’s need for same day emergency care.
The Trustees find that the Employer is required to provide benefits for the emergency room charge resulting from the Employee’s evaluation and treatment on January 2, 1992.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charges resulting from the Employee’s evaluation and treatment on January 2, 1992.
Opinion of Trustees Resolution of Dispute Case No. 88-595
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