受托人的意见
争议的解决
情况下没有. 88-560
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OPINION OF TRUSTEES _____________________________________________________________________________
在再保险
投诉人:被投诉人:ROD案件编号:
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. 西格尔,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 States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room care under the terms of the 雇主 Benefit Plan.
背景事实
On November 3, 1991, the 员工’s son complained of abdominal pain. The 员工 and his son agreed that the pain may have been caused by a muscle pulled during a football game at school. 在周五, 11月8日, 1991 the 员工’s son came home from school saying the pain had become more severe. The 员工 immediately called his family physician, whose schedule was too full to examine the son. The 员工 then took his son to the emergency room of the local hospital where he was evaluated and treated. 急诊室的医生, after ruling out any spleen trauma or a subcapsular hematoma of the spleen, arrived at the final diagnosis of viral infection.
The 雇主 rejected the charges for the emergency room and all x-ray and laboratory charges, 还有医疗用品的费用, on the basis that the 员工 did not seek treatment for his son within 48 hours of the onset of symptoms. The 员工 is appealing the decision based on the fact that the symptoms did not become acute until the day he sought treatment for his son, thereby falling within the 48 hour time limitation.
争端
Is the 雇主 required to provide benefits for the emergency room charge resulting from the 员工’s son’s evaluation and treatment on 11月8日, 1991?
双方立场
员工
雇主
88-560——1992年7月15日
受托人的意见 争议的解决 情况下没有. 88-560
第二页
Position of the 员工: The 雇主 is required to provide benefits for the emergency room charge incurred by the 员工’s son on 11月8日, 1991 because the treatment was sought within 48 hours of the time when the symptoms became acute.
Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room charge incurred by the 员工’s son on 11月8日, 1991 because the initial onset of symptoms occurred more than 48 hours prior to the hospital visit.
Pertinent Provisions The Introduction to 第三条 states in pertinent part:
第三条-福利
Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定. The fact that a procedure or level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan….
第三条. A. (2) (a) of the 雇主 Benefit Plan states: (2) Outpatient Hospital Benefits
(a)紧急医疗和事故案件
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
The Introduction of 第三条 of the 雇主 Benefit Plan states that the Plan covers services which are rendered at the appropriate level of care. 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.
A Funds’ medical consultant has reviewed this case and has determined, 从可用的文档中, that the 员工’s son’s symptoms had worsened in the preceding 48 hours, thereby necessitating the emergency room visit. The consultant stated that the medical record indicates that the physical examination done by the emergency room physician was positive for significant pain in the left upper quadrant with a question of an enlarged spleen. Given the patient’s history for potential trauma from playing football, the consultant was of the opinion that the emergency
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room visit, laboratory work and x-rays (including the C.T. scan) are medically appropriate to evaluate the condition.
因此, the 雇主 is required to provide benefits from the 员工’s son’s emergency room visit on 11月8日, 1991 as it was precipitated by a worsening of the symptoms within the preceding 48 hours.
受托人的意见
The 雇主 is required to provide benefits for the emergency room charge, 包括所有的x射线, 化验费和医疗用品, incurred by the 员工’s son on 11月8日, 1991.