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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
Trustees: Wallace.
Employee
Employer
88-831 – July 12, 1995
In Re
Thomas F. Connors, Michael H. Holland, Marty D. Hudson and Robert T.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room care under the terms of the Employer Benefit Plan.
Background Facts
The Employee’s spouse went to an area hospital emergency room on June 4, 1993. The emergency room record notes that she had right flank pain, burning on urination and vomited the night before. She was under the care of her attending physician for prior back problems, but his office was closed at the time when she felt her symptoms became “unbearable.” The patient is an insulin dependent diabetic.
The Employer provided benefits for the physician’s charge, but denied benefits for the emergency room charge of $63.00, the laboratory charge of $284.00 and the pharmacy charge of $28.00.
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 charge of $63.00, the laboratory charge of $284.00 and the pharmacy charge of $28.00?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the emergency room and associated charges incurred by the Employee on June 4, 1993.
Opinion of Trustees
ROD Case No. 88-831
Page 2
Position of the Employer: The Employer is not required to provide benefits for the emergency room and associated charges since the treatment was not rendered at an appropriate level of care, nor were acute medical symptoms present.
Pertinent Provision
Article III A. (2) (a) states: Article III: Benefits
A. Health Benefits
(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 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 benefits for emergency medical treatment when it is rendered within 48 hours of the onset of acute medical symptoms.
A Fund’s medical consultant has reviewed the emergency room records in this case and notes that the medical records contain no documentation of a sudden worsening of her condition. He notes that, because the patient is an insulin dependent diabetic, it was important that she be evaluated for a urinary tract infection. Further, the Fund’s medical consultant found no indication in the medical documentation of new, acute or life threatening symptoms. Accordingly, he is of the opinion that the treatment in the emergency room was not the appropriate level of care in this instance. Therefore, under the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the use of the emergency room, but is required to provide benefits for the laboratory and pharmacy charges incurred during the visit, since these would have been incurred in a visit at an outpatient clinic or physician’s office.
Opinion of Trustees ROD Case No. 88-831 Page 3
Opinion of the Trustees
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the emergency room charges for the Employee’s visit on June 4, 1993, but is required to provide benefits for the laboratory and pharmacy charges.