受托人的意见
争议的解决
情况下没有. 81-307
第1页 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
81-307——1983年8月29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, 受托人 have reviewed the facts and circumstances of this dispute concerning payment of private room charges under the 雇主’s Plan and hereby render their opinion in the matter.

背景事实

The 员工 was hospitalized at the Holston Valley Hospital and Medical Center from January 28, 1983年至2月18日, 1983, 在圣. Mary’s Hospital from March 19, 1983年至4月2日, 1983. During both admissions, the 员工 was confined in a private room. The 员工 contends that his physicians had recommended that he be placed in a private room, and therefore the 雇主 should pay the private room rate. Regarding the 员工’s hospitalization at Holston Valley Hospital, Dr. J. Michael Bookout stated that “I felt it was necessary that he have a private room during this hospitalization to improve progress.” Addressing the 员工’s private room confinement at St. 玛丽医院. G.S. Kanwal stated that “I believe his being treated in a private room helped his improvement of his nerves.” The 雇主 provided coverage in an amount equal to the hospitals’ most common charges for semi-private room accommodations, but denied payment for the private room charges.

问题或争议

Is the 雇主 responsible for coverage of charges for private room rates in excess of the charges for semi-private room accommodations during the 员工’s two hospital stays.

各方立场

Claimant’s Position: The 雇主 is responsible for the private room charges since the 员工’s 医生tors recommended a private room due to the condition of his nerves.

受托人的意见 争议的解决 情况下没有. 81-307
第二页

雇主’s Position: According to 第三条 A (1) (c) of the 雇主’s Benefit Plan, benefits for private room charges are only allowed under special circumstances. 因为Dr。. 我不是博士。. Kanwal certified that the 员工’s confinement in a private room was required to isolate him for his own health or the health of others, and because there is no evidence that semi-private room accommodations were not available, the 雇主 determined that the 员工’s confinement in a private room was not medically necessary and did not satisfy the provisions of the plan. 付款 of charges for a private room should therefore be denied.

相关的规定
第三条, Section A (1) (c) of the 雇主’s Plan provides as follows:

被关在单独的房间里, benefits will be provided for the hospital’s most common charge for semi-private room accommodations and the Beneficiary shall be responsible for any excess over such charge except that private room rates will be paid when (i) the Beneficiary’s condition requires him to be isolated for his own health or that of others, or (ii) the hospital has semi-private or less expensive accommodations but they are occupied and the Beneficiary’s condition requires immediate hospitalization. 半私人房间价格, 非私人房费, will be paid beyond the date a semi-private room first becomes available and the Beneficiary’s condition permits transfer to those accommodations.

第三条, Section A (11) (a) (10) of the 雇主’s Benefit Plan provides under General Exclusions as follows:

In addition to the specific exclusions otherwise contained in the Plan, benefits are also not provided for the following:

(10) Charges for private room confinement, except as specifically described in the Plan.

讨论

Pursuant to 第三条 A 1 (c) of the 雇主’s Benefit Plan, an 雇主 is responsible for the payment of private room rates when an 员工’s condition requires him to be isolated for his own health or that of others, or if the 员工 requires immediate hospitalization and only a private room is available because all semi-private or less expensive accommodations are occupied.

Since the evidence provided by the 员工 in support of his claim does not establish that his confinement in a private room was due to a condition which required isolation for his own health or that of others, and because there is no indication that a semi-private room was unavailable, the 雇主 is not responsible for payment of the private room charges.

受托人的意见 争议的解决 情况下没有. 81-307
第3页

受托人的意见

根据文件中的信息, 受托人, 受托人库姆斯不同意, are of the opinion that the 雇主 is not responsible for the difference between the private and semi-private room rates for the 员工’s hospitalizations from January 28, 1983年至2月18日, 1983, 3月19日起, 1983年至4月2日, 1983.