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OPINION OF TRUSTEES
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In Re

Complainant: Surviving Spouse
Respondent: Employer
ROD Case No: CA-068 – July 13, 2005

Trustees: Micheal W. Buckner, A. Frank Dunham, Michael H. Holland, and
Elliot A. Segal.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Coal Industry Retiree Benefit Act of 1992 (Coal Act) Employer Benefit Plan maintained pursuant to section 9711 of the Internal Revenue Code.

Background Facts

After experiencing vaginal bleeding for five days, the 64 year-old Complainant sought treatment at the emergency room on February 21, 2001. The Complainant stated that she felt very weak prior to her visit to the emergency room. The Respondent provided coverage for the treatment the Complainant received but denied coverage for the emergency room charge.

Dispute

Is the Respondent required to provide coverage for the emergency room charge for the Complainant’s visit on February 21, 2001?

Positions of the Parties

Position of the Complainant: The Respondent is required to provide benefits for the emergency room charge because the Complainant was ill and had to see a doctor.

Position of the Respondent: The Respondent is not required to provide benefits for the emergency room charge because the Complainant’s condition was not acute but was ongoing for six days prior to her visit to the emergency room.

Pertinent Provisions

Article III A. (2) (a) of the Coal Act Employer Benefit Plan states:

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

Article III A. (2) (a) provides benefits for emergency medical treatment rendered within 48 hours following the onset of acute medical symptoms.

The Funds’ Medical Director has reviewed the medical documentation submitted in this case. The Medical Director notes that the Complainant’s medical history and physical examination do not indicate that any acute changes or findings had developed in the 24 to 48 hour period prior to her visit to the emergency room that necessitated an emergency visit. Therefore, under the provisions of the Coal Act Employer Benefit Plan, the Respondent is not required to provide coverage for the use of the emergency room.

Opinion of the Trustees

The Respondent is not required to provide coverage for the emergency room charge for the Complainant’s visit on February 21, 2001.