Opinion of Trustees
Resolution of Dispute
Case No. 88-616
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-616 – 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 16, 1991, the Employee sought medical evaluation and treatment for his twelve- year-old daughter at a hospital emergency room for symptoms of fever, aching all over, chest congestion and headache. The patient’s temperature was documented at 102 degrees F in the emergency room record. The onset of symptoms was recorded as having occurred the previous day, according to a letter sent to the Employer by the claims administrator. The emergency room physician prescribed antibiotics and cough syrup for bronchitis and advised the patient to return later that day if there were any further problems.
The Employer provided benefits for the physician charge, but denied the emergency room charge incurred on December 16, 1991.
Dispute
Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on December 16, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room charge incurred on December 16, 1991 because acute symptoms appeared within 48 hours of the emergency room visit.
Opinion of Trustees Resolution of Dispute Case No. 88-616
Page 2
Position of the Employer: The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on December 16, 1991 because there is no evidence that her symptoms were acute and 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 benefits are provided for emergency medical treatment 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 is of the opinion that, due to the nature of the symptoms, including the documented fever of 102 degrees F and the history of headache, and the young age of the patient, the parents could not have been expected to determine whether the patient’s condition required immediate treatment. Further, the consultant stated that, because of this uncertainty and because, in his opinion, the medical symptoms were acute, the visit to the emergency room was appropriate in this case. Because the Employee’s daughter had developed acute medical symptoms within 48 hours that warranted an emergency room visit, the Trustees conclude that the Employer is required to provide benefits for the emergency room charge.
Opinion of the Trustees
The Employer is required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on December 16, 1991.