Opinion of Trustees
Resolution of Dispute
Case No. 88-514
Page 1 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Pensioner
Employer
88-514 – March 20, 1992
Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, 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 emergency room expenses under the terms of the Employer Benefit Plan.
Background Facts
On June 18, 1991 the spouse of an Employee sought treatment at the regional medical center for the acute symptoms of a urinary tract infection. The day of the visit the patient complained of an orange discharge, burning upon urination, and pressure and pain in her lower back. The laboratory studies of her urine, and the history and physical done at the hospital, were sufficient enough to warrant starting her on antibiotics and pain medication. She was advised to return In two days if the symptoms persisted or worsened, and to have a repeat urinalysis in 10 days.
The Employer submitted the bills in connection with his spouse’s Illness to the Employer for payment. The Employer paid the bill for the emergency room physician, but denied benefits for the emergency room charge.
Dispute
Is the Employer required to pay for emergency room charge resulting from the Employee’s spouse’s treatment on June 19, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to pay for the emergency room charge resulting from the Employee’s spouse’s evaluation and treatment on June 19, 1991 because treatment was rendered within 48 hours of the onset of acute medical symptoms.
Opinion of Trustees Resolution of Dispute Case No. 88-514
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Position of the Employer: The Employer is not required to pay for the Employee’s spouse’s emergency room charge because there is no indication that treatment was rendered within 48 hours of the onset of acute medical symptoms or the occurrence of an accident.
Pertinent Provisions Article III. A. (2) (a) of the Employer Benefit Plan provides:
(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 or the occurrence of an accident.
A Fund’s medical consultant has reviewed this file and determined that the Employee’s spouse’s emergency room visit on June 19, 1991 should be considered appropriate due to the acute medical symptoms present, and because the emergency care was sought within 48 hours of the onset of the acute symptoms. It is the consultant’s opinion that the visit was medically justified because her symptoms, and the results of her laboratory studies and history and physical done by the emergency room physician, were of enough concern to warrant prescribing antibiotics and pain medication. Additionally, her condition was such that catheterization was necessary in order to obtain a urine sample.
For these reasons, it is the opinion of the Trustees that the Employer is required to pay for the Employee’s spouse’s June 19, 1991 emergency room visit.
Opinion of the Trustees
The Employer is required to pay the payment of the emergency room charge incurred by the Employee’s spouse on June 19, 1991.