OPINION OF TRUSTEES ______________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

受托人:

在再保险

养老金领取者
雇主
2016 - 2018年3月28日

迈克尔·H. 霍兰德，马蒂·D. 迈克尔·哈德逊. 麦科恩和约瑟夫. 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’s spouse went to the local emergency room on Friday April 22, 2016, 大约七点零五分.m. Her chief complaints were reported as being a severe headache and nausea that started the previous day, and high blood pressure from that morning. Emergency room records indicate that she did not report any symptoms of chest pain. A physical examination and lab tests were within normal parameters. She was diagnosed with an occipital headache and seasonal allergic rhinitis. The emergency room treated her with ondansetron for the nausea and with intramuscular ketorolac for the headache. She was released and directed to follow up with her primary physician.

The Respondent denied the emergency room facility charges because the patient’s symptoms had been present for more than 48 hours without an increase in severity and treatment should have been sought at a lower level of care. The Respondent paid the associated physician charges for the April 22, 2016, emergency room visit.

争端

Is the Respondent required to pay for the emergency room facility charges for the Complainant’s spouse’s visit to the emergency room on April 22, 2016?

双方立场

Position of the Complainant: The charges are a covered benefit under the 雇主 Benefit Plan. The Complainant’s spouse sought appropriate medical care for the symptoms that she experienced as she thought they were related to a possible heart attack.

受托人的意见，ROD个案编号. 第2页

Position of the Respondent: The emergency room facility charges are not covered by the 雇主 Benefit Plan because the Complainant’s spouse’s symptoms were present for more than 48 hours and the treatment notes do not show an acute worsening of symptoms. Treatment should have been sought at a lower level of care. The associated physician charges were covered for the April 22, 2016 emergency room visit.

有关规定.(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.

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 the treatment is rendered within 48 hours following the onset of acute medical symptoms. The Complainant’s spouse reported that she had a headache since the previous day and nausea. On Friday April 22, 2016, she went to the emergency room because the symptoms had not gone away. 她没有胸痛. The emergency room diagnosis was occipital headache, headache, and seasonal allergic rhinitis.

的资金’ Medical Director reviewed the emergency room medical records and a statement from the Complainant and determined that while the Complainant’s spouse’s emergency room visit met the 48-hour timeline it did not meet the acuity level required for coverage of medical services under the 雇主 Benefit Plan. The Complainant indicated in his statement that his spouse was experiencing chest pressure and pain that radiated down her left arm in addition to a headache and nausea. 然而, the medical records indicate that the Complainant’s spouse

受托人的意见，ROD个案编号. 第3页

denied having chest pain three times during her assessment and collection of medical history. 进一步, the medical records do not reveal that the Complainant’s spouse’s symptoms were severe enough to be considered acute, as there was no report of chest discomfort or heart palpitations.

因此, the charges associated with the visit to the emergency room on April 22, 2016, are not a covered benefit under the 雇主 Benefit Plan. The 雇主 is therefore only responsible for any associated charges that are otherwise covered by the Plan. It appears that the physician charges were paid by the 雇主.

受托人的意见

根据第三条.雇主福利计划A(2)(A)项, the Respondent is not required to pay facility charges for Complainant’s spouse’s emergency room visit on April 22, 2016. 然而, the 雇主 is responsible for any associated charges that are otherwise covered by the 雇主 Benefit Plan.