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OPINION OF TRUSTEES
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In Re

Complainant: Employee
Respondent: Employer
ROD Case No: 88-696 – February 16, 1995

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 benefits for emergency room treatment under the terms of the Employer Benefit Plan.

Background Facts

On June 18, 1992, the Employee sought medical evaluation and treatment for his four-month-old dependent daughter at a hospital emergency room. The Employee has stated that his daughter was running a temperature of over 100 degrees and experiencing chills. The Employee further stated that the time was approximately 4:30 or 5:00 PM and there were no doctors’ offices open. The emergency room physician diagnosed colic and constipation, recommended a suppository and continued prune/apple juice, and released her.

The Employer has stated that it provided benefits for the physician’s charge for the Employee’s daughter’s treatment, but denied benefits for the emergency room charge, stating that there is no evidence in the medical record of acute symptoms requiring emergency treatment within 48 hours of the emergency room visit.

Dispute

Is the Employer required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s medical evaluation and treatment on June 18, 1992?

Positions of the Parties

Position of the Employee: The Employer is required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s emergency room visit on June 18, 1992 because the medical symptoms she was experiencing and her very young age required medical assistance and no doctors’ offices were open.

Position of the Employer: The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s emergency room visit on June 18, 1992 because there were no acute medical symptoms that required emergency medical treatment.

Pertinent Provisions

Article III. A. (2)(a) of the Employer Benefit Plan provides:

(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 benefits for emergency medical care when rendered within 48 hours following the onset of acute medical symptoms. A Funds’ medical consultant has reviewed the medical records in this case and has advised that the record indicates normal vital signs and no evidence of acute problems or symptoms. The consultant stated that the record shows that the patient had been having symptoms of colic for one month and was seen by her personal physician on May 29, 1992 and placed on therapy. He is of the opinion that there is no medical evidence of acute or worsening medical symptoms prior to the June 18, 1992 emergency room visit. Because there is no evidence of acute or worsening symptoms, the Trustees conclude that the Employee’s daughter’s emergency room charge is not covered under the Employer Benefit Plan.

The Employee stated that on the day of the emergency room visit, his daughter had a temperature over 100 degrees and that no doctors’ offices were open since the time was 4:30 or 5:00 PM. This information, however, is not supported by the emergency room record, which reports a temperature of 98.9 degrees and a time of 3:30 PM upon arrival.

Opinion of the Trustees

The Employer is not required to provide benefits for the emergency room charge resulting from the Employee’s daughter’s evaluation and treatment on June 18, 1992. The Employer is, however, required to provide benefits for any X-rays, laboratory tests, or physician’s charges in connection with the emergency room visit.