受托人的意见
争议的解决
情况下没有. 88-616
第1页 _____________________________________________________________________________
OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: ROD 情况下没有:
在再保险
员工
雇主
88-616 - 1992年9月21日
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
12月16日, 1991, the 员工 sought medical evaluation and treatment for his twelve- year-old daughter at a hospital emergency room for symptoms of fever, 全身疼痛, 胸闷头痛. The patient’s temperature was documented at 102 degrees F in the emergency room record. The onset of symptoms was recorded as having occurred the previous day, according to a letter sent to the 雇主 by the claims administrator. The emergency room physician prescribed antibiotics and cough syrup for bronchitis and advised the patient to return later that day if there were any further problems.
The 雇主 provided benefits for the physician charge, but denied the emergency room charge incurred on December 16, 1991.
争端
Is the 雇主 required to provide benefits for the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on December 16, 1991?
双方立场
Position of the 员工: The 雇主 is required to provide benefits for the emergency room charge incurred on December 16, 1991 because acute symptoms appeared within 48 hours of the emergency room visit.
受托人的意见 争议的解决 情况下没有. 88-616
第二页
Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on December 16, 1991 because there is no evidence that her symptoms were acute and required emergency treatment.
Pertinent Provisions 第三条. A. (2) (a) of the 雇主 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.
讨论
第三条. A. (2) (a) of the 雇主 Benefit Plan provides that benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and is of the opinion that, due to the nature of the symptoms, including the documented fever of 102 degrees F and the history of headache, and the young age of the patient, the parents could not have been expected to determine whether the patient’s condition required immediate treatment. 进一步, 顾问说, because of this uncertainty and because, 在他看来, the medical symptoms were acute, the visit to the emergency room was appropriate in this case. Because the 员工’s daughter had developed acute medical symptoms within 48 hours that warranted an emergency room visit, the Trustees conclude that the 雇主 is required to provide benefits for the emergency room charge.
受托人的意见
The 雇主 is required to provide benefits for the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on December 16, 1991.