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OPINION OF TRUSTEES
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In Re
Complainant: Employee
Respondent: Employer
ROD Case No: 88-584 – September 29, 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 medical care under the terms of the Employer Benefit Plan.
Background Facts
On May 2, 1991, the Employee’s spouse sought treatment at a local hospital emergency room complaining of pain in her arms and legs. The emergency room record indicates that the pain had begun three weeks before, although in the ROD statement the Employee’s spouse maintains that the symptoms had worsened sufficiently enough in the prior 48 hours to cause her to seek emergency medical care. The Employer paid the physician’s charge but denied the charges for the emergency room and the laboratory tests on the basis that the emergency care was not medically necessary and that care was not rendered within 48 hours of the onset of the condition. The Employee requests that the Trustees intervene on his behalf.
Dispute
Is the Employer required to provide benefits for the Employee’s spouse’s use of the emergency room on May 2, 1991?
Positions of the Parties
Position of the Employee: The Employer is required to provide benefits for the Employee’s spouse’s use of the emergency room on May 2, 1991 because her symptoms had become acute within the preceding 48 hours, causing her to seek emergency medical care.
Position of the Employer: The Employer is not required to provide benefits for the Employee’s spouse’s use of the emergency room on May 2, 1991 because the spouse’s symptoms had been present for three weeks and therefore the emergency care was not rendered within 48 hours of onset of acute medical symptoms.
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 for emergency medical care when rendered within 48 hours of the onset of acute medical symptoms or the occurrence of an accident.
The Employee’s spouse reported to the emergency room staff that the pain in her arms and legs had begun approximately three weeks prior to the visit.
A Funds’ medical consultant has reviewed the file and notes that there is no documentation of new or acute exacerbation of pain within the prior 48 hours. Without documentation of a new or acute pain within 48 hours of the visit, the consultant is of the opinion that the emergency department visit on May 2, 1991 does not meet the requirements as set out in Article III. A. (2) (a) of the Employer Benefit Plan. The charges for the laboratory tests would have been incurred regardless of the setting, and the Employer is required to provide benefits for these.
Opinion of the Trustees
The Employer is not required to provide benefits for the emergency room charge for the Employee’s spouse’s use of the emergency room on May 2, 1991, but Is required to provide benefits for the laboratory tests incurred during the visit.