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OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: ROD Case No:

在再保险

员工
雇主
1982年12月20日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.

Pursuant to Article IX of the United Mine Workers of America 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 payment of emergency room charges, and hereby render their opinion on the matter.

背景事实

The 员工 is an active mine worker eligible for health benefits under the 雇主’s Plan. 8月11日, 1981, he took his 16 year old dependent child to the emergency room of a hospital for treatment. The 员工’s representative stated that the 员工 used his best judgment when he took his daughter to the emergency room for treatment of influenza. The emergency room record indicates that the patient’s chief complaint was “too much spit” and that the patient had a history of too much saliva being produced over the past two months. The emergency room diagnosis was possible “post nasal drip.” The 雇主 paid the charges for the physician and for lab work, but denied the $27.急诊室收费00.

争端

Is the 雇主 responsible for payment of emergency room charges for the 员工’s dependent?

各方立场

Position of 员工’s Representative: The emergency room charge should be a covered benefit because the 员工, 以他最好的判断, 把他的依赖性带到那里.

Position of the 雇主: The emergency room charge is not covered because this case cannot be considered a valid emergency medical situation requiring emergency treatment.

Opinion of Trustees Resolution of 争端 Case No. 81-96
第二页

第三条有关规定. A. (2) (a) of the 雇主’s Benefit Plan provides:

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.

1981 Question and Answer #81-10 provides:

Subject: Definition of emergency Treatment Benefit

References:Amended 1950 and 1974 Benefit Plans and Trusts, 第三条, 第A (2) (A)及A (3) (i)条

问题:

Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.

1. Would emergency treatment for conditions such as the following be covered under this provision:
   • -痛风引起的急性疼痛?
   • –  heart attack, severe chest pain, or congestive failure experienced by a

     患有(慢性)心脏病的病人?

   • –  intracranial bleeding or stroke experienced by a patient with hypertension?
2. Are benefits provided for inpatient and outpatient hospital and physicians’ services following emergency treatment beyond the 48-hour initial care limit (for example, 拆除缝线或拆除石膏)?

答:

1. 是的, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms-may be chronic.
2. 是的, if the follow-up treatment is covered under the Plan.

Opinion of Trustees Resolution of 争端 Case No. 81-96
第3页

讨论

Q&第81-10条和第三条. A. (2) (a) of the 雇主’s Benefit Plan provide that for emergency medical treatment to be a covered benefit, it must be rendered within 48 hours following the onset of acute medical symptoms.

The emergency room record indicates that the patient’s chief complaint of over-production of saliva had persisted for two months prior to the date she obtained emergency room treatment and the record does not indicate that her medical symptoms had become acute.

的资金’ medical staff reviewed the clinical information presented in this case. They are of the opinion that the symptoms and clinical finding, 记录, did not justify emergency medical treatment.

Because it has been determined that the patient’s condition did not warrant emergency medical treatment and because the treatment was not rendered within 48 hour of the onset of acute symptoms, the 雇主 is not responsible for payment of the emergency room charges.

受托人的意见

The Trustees are of the opinion that the 雇主 is not responsible for payment of the emergency room charges.