受托人的意见
争议的解决
情况下没有. 88-487
第1页 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD 情况下没有:
在再保险
员工
雇主
88-487 - 1992年4月14日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,受托人.
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 Stated Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning provision of benefits for emergency room care under the terms of the 雇主 Benefit Plan.
背景事实
7月13日, 1991, the 员工 sought medical evaluation and treatment for his 11-month-old daughter at a hospital emergency room. The child had a 103 degree fever and the emergency room physician diagnosed otitis media and prescribed Ceclor to treat the infection and Tylenol for symptomatic relief. The emergency room visit was considered a medical emergency, and the charged for this visit were paid by the 雇主.
7月16日, 1991, the 员工 again sought medical evaluation and treatment for his daughter at the hospital emergency room. The emergency room records indicate that a rash had developed on the patient’s body. The emergency room records indicate a temperature of 97.9度. The emergency room physician’s report states that the patient’s rash could have been an allergic reaction, although it looked more like a roseola rash. The physician noted that the child’s ear drum was still red. The physician changed the prescribed medications from Ceclor and Tylenol to Septra and PediaProfen.
The 雇主 denied the emergency room charge for the July 16, 1991 visit on the grounds the 员工’s daughter’s condition did not require emergency medical treatment.
争端
Is the 雇主 required to pay the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on July 16, 1991?
各方立场
受托人的意见 争议的解决 情况下没有. 88-487
第二页
Position of the 员工: The 雇主 is required to pay the emergency room charge incurred on July 16, 1991 because emergency treatment was necessary.
Position of the 雇主: the 雇主 is not required to pay the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on July 16, 1991 because there is no evidence that her symptoms had worsened or required emergency medical treatment.
第三条有关规定. A. (2) (a) of the 雇主 Benefit Plan states:
(2)医院门诊福利
(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.
讨论
第三条. A. (2) (a) of the 雇主 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.
The emergency room records indicates that the 员工’s daughter was being treated with the antibiotic Ceclor for otitis media and that she had developed a rash on her body prior to the July 16, 1991年急诊室就诊.
A Funds’ medical consultant has reviewed the medical records in this case and has advised that the rash developed by the patient could have been viral in nature, or indicative of the progression of an allergic reaction, 细菌感染, 或者是一种精神状态. The consultant is of the opinion that the rash needed to be evaluated that day, as it was a new physical finding of less than 48 hours duration. 根据记录, the physician finding of the patient felt that the rash could possibly have been caused by the Ceclor, so he discontinued that medication and started the patient on another antibiotic. 出于这些原因, the medical consultant has advised that the visit of July 16, 1991 was warranted for evaluation and treatment of new symptoms that were reasonably judged to be acute.
受托人的意见
The 雇主 is required to pay the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on July 16, 1991.