OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

在再保险

员工
雇主
11-0118 - 2015年12月14日

迈克尔·H. 霍兰德，马蒂·D. 哈德逊和约瑟夫. Reschini

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实

The Complainant and his spouse sought medical care for their two year-old son at the local emergency room on Wednesday, 12月26日, 2012, 下午3点33分.m. The parents reported that the child awoke from sleep and would not stop crying. Emergency room records noted that the child had been treated with antibiotics for an upper respiratory infection the previous week at a local urgent care center and that the child’s cough had become worse “today” before the 急诊室就诊. 在考试, the child’s vital signs were normal, 他泪流满面，满腹牢骚, his oral cavity and throat were normal, and his tympanic membranes (ear drums) were red and bulging bilaterally. The emergency room physician diagnosed the child as having 双侧中耳炎. Although the upper respiratory infection was treated the previous week, it had evolved into a second illness, 双侧中耳炎, which caused new and acute symptoms that occurred within 24 hours of the 急诊室就诊.

The Respondent denied all charges as non-covered services. An appeal was file with the Respondent’s Third Party Administrator, but no communications have been submitted as to the appeal’s status.

争端

Is the Respondent responsible for the emergency room facility services and the associated physician charges for the 12月26日, 2012, 访问?

Opinion of Trustees ROD Case No. 11-0118页2

双方立场

Position of the Complainant: The charges are a covered benefit under the 雇主 Benefit Plan. The services rendered to treat the patient’s illness were medically necessary and meet the criteria for coverage for emergency services under the Plan.

Position of the Respondent: The Respondent did not submit a response to the complaint.

Pertinent Provisions 第三条 A (2) (a) of the 雇主 Benefit Plan states:

第三条利益a. 健康的好处

(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 states that benefits will be provided for emergency medical treatment when such treatment is provided within 48 hours following the onset of acute medical symptoms. The child’s initial illness was an upper respiratory infection that started a week before the 急诊室就诊. Based on the emergency room records, 这种病得到了治疗, but it had evolved into a second illness, 双侧中耳炎. The 双侧中耳炎 caused new and acute symptoms that occurred within 24 hours of the 急诊室就诊. 的资金’ Medical Director has reviewed the medical records submitted and opined that the ear infections (双侧中耳炎) meet the criteria for emergency treatment, since the ear infections can be considered separate from the initial upper respiratory infection and the child’s illness became acute less than 48 hours before treatment in the emergency room. 因此, the employer should be responsible for the emergency room facility charges, the physician charges and any other ancillary charges associated with the 急诊室就诊 of 12月26日, 2012.

Opinion of Trustees ROD Case No. 11-0118页3

受托人的意见

根据第三条.A.(2)(a) of the 雇主 Benefit Plan, the Respondent is required to pay the emergency room facility charges, the physician charges and any other ancillary charges associated with the 12月26日, 2012, 急诊室就诊.