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OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
Employee Employer
88-787 – July 12, 1995
In Re
Trustees: Thomas F. Connors, Michael H. Holland, Marty D. Hudson and Robert T. Wallace.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room charges under the terms of the Employer Benefit Plan.
Background Facts
On Saturday, March 27, 1993, the Employee’s daughter sought evaluation and treatment at a local hospital emergency room, complaining of flu symptoms which began two weeks prior to the visit. The Employee states that his daughter’s symptoms had worsened the day of the visit, necessitating the emergency care. Additionally, the Employee states that the daughter’s family physician was unavailable.
The emergency room physician ordered the Employee’s daughter’s ears to be irrigated, and prescribed medications for use at home. According to the medical records, the Employee’s daughter’s vital signs were within normal ranges, and she did not appear in any acute distress.
The Employer has provided benefits for the emergency room physician’s charge, but is denying the emergency room charge because treatment was not sought within 48 hours of the onset of symptoms.
The Employer was signatory to the 1988 National Bituminous Coal Wage Agreement (Wage Agreement) which terminated February 1, 1993. The Employer signed an Interim Agreement extending the terms and conditions of employment of the l988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1994.
Dispute
Is the Employer required to provide benefits for the emergency room charges resulting from the Employee’s daughter’s evaluation and treatment on March 27, 1993?
Positions of the Parties
Opinion of Trustees Resolution of Dispute Case No. 88-787 Page 2
Position of the Employee: The Employer is required to provide benefits for the Employee’s daughter’s emergency room visit on March 27, 1993, because the symptoms worsened the day of the visit, necessitating the emergency treatment.
Additionally, the Employee’s family physician was unavailable as it was a Saturday.
Position of the Employer: The Employer is not required to provide benefits from the emergency room charges incurred by the Employee’s daughter on March 27, 1993, because the care was not sought within 48 hours of the onset of symptoms.
Pertinent Provisions Article III.A.(2)(a) of the Employer Benefit Plan states:
(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 Employer was signatory to the 1988 Wage Agreement. The Employer signed an Interim Agreement extending the terms and conditions of employment of the 1988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1993. This dispute arose over an event that took place during the period covered by the Interim Agreement.
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 indicates that the Employee’s daughter had symptoms of the flu for two weeks prior to the emergency room visit. The Employee stated that his daughter’s symptoms had worsened the day of the emergency room visit; however, the emergency room record makes no mention of an acute exacerbation of his daughter’s symptoms.
A Funds’ medical consultant has reviewed the information presented in this case and has advised that a review of the history, physical examination, vital signs, diagnosis, and treatment, does not provide documentation of any new or worsening symptoms that would meet the criteria of Article III.A.(2)(a) of the Employer Benefit Plan. Therefore, the consultant is of the opinion that the Employee’s daughter’s emergency room visit on March 27, 1993, would not be considered medically appropriate.
Opinion of Trustees Resolution of Dispute Case No. 88-787 Page 3
The Trustees conclude, in accordance with the provisions of the Plan, that The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on March 27, 1993.
Opinion of the Trustees
In accordance with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on March 27, 1993.