OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
受托人:
在再保险
养老金领取者
雇主
11-0126 - 2016年7月27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 is a pensioner receiving health benefits coverage from the Respondent. The Complainant’s spouse sought treatment at the local emergency room on Thursday October 11, 2012, 下午1:20.m. for pain in her face, neck and ear. The patient has a long history of chronic facial, neck and ear pain and was under the care of a pain specialist. Her examination was essentially normal and she was discharged with a pain medication and instructions to follow-up with her primary care physician.
The Respondent initially denied all of the emergency room charges. Subsequent to the filing of a request for resolution of dispute the Respondent paid the ancillary charges for the emergency room physician and $12.药费的80%.
争端
Is the Respondent required to provide benefits for the Complainant’s spouse’s emergency room visit on October 11, 2012?
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 met the criteria for coverage for emergency services under the Plan.
Position of the Respondent: The Respondent’s position is that the Complainant’s spouse did not seek treatment at the emergency room within 48 hours of the onset of acute symptoms and the severity and urgency of her condition did not warrant emergency room care. Also, take home medications are excluded under the Plan.
受托人的意见，ROD个案编号. 11-0126页
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)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.
第三条.A(4)(b) of the 雇主 Benefit Plan states:
第三条利益a. 健康的好处
(4)处方药
(b)排除的福利
Benefits shall not be provided under subsection (4)(a) for the following:
1. Medications dispensed in a hospital (including take-home drugs), skilled nursing facility or physician’s office. (See 第三条 A (1)(a) and (5)(a) for benefits provided for drugs and medications during inpatient confinement in a hospital skilled nursing facility.)
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. 的资金’ Medical Director has reviewed the medical records submitted and opined that the patient’s symptoms started four to six days before the emergency room visit. 进一步, the records did not indicate that the symptoms progressed within 48 hours preceding the emergency room visit so as to qualify as new acute medical symptoms.
第三条.A.(4)(b)1 does not require payment for medications dispensed in a hospital for the patient to take home. The records show that upon discharge the patient received medication for pain.
受托人的意见，ROD个案编号. 11-0126页
基于上述, the emergency room facility charges for the visit by the Complainant’s spouse on October 11, 2012, and the charge for medication that she took home (in the amount of $61.00) do not satisfy the criteria necessary to be covered under the Plan. The Complainant’s spouse did not meet the 48 hour requirement for emergency services and take home medication is specifically excluded under the Plan. 因此, the 雇主 should not be responsible for the emergency room facility charges or the take home medication.
受托人的意见
根据第三条.A(2)(A)和第三条.A(4)(b) of the 雇主 Benefit Plan, the Respondent is not required to pay for the Complainant’s spouse’s emergency room facility charge for the October 11, 2012, emergency room visit and is not required to pay for the medications that were taken home.