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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-352——1987年7月17日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 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 the provision of benefits for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

3月5日, 1986, the 员工’s spouse presented herself at the emergency room of a local hospital for treatment. According to the information submitted, the 员工’s spouse had experienced cold symptoms for almost a week. She decided to seek treatment at the emergency room when minor chest pains accompanied her cold symptoms and “the thought of possible pneumonia entered her mind.” She did not have a family physician.

急诊室的记录 indicates that the patient’s chief complaint was “chills, 全身疼痛, 喉咙痛和头痛, 上周.” The emergency room physician stated that the patient had persistent symptoms of a mild throat infection, and diagnosed the spouse’s condition as sinusitis. The 雇主 paid the charges for the services of the emergency room physician but denied payment for the emergency room charge.

争端

Is the 雇主 responsible for payment of the emergency room charges resulting from the 员工’s spouse’s visit on March 5, 1986?

双方立场

Position of the 员工: The emergency room charge should be a covered benefit because the employee’s spouse sought medical treatment at a time when she believed she needed to be evaluated by a 医生tor.

Position of the 雇主: The emergency room charge is not covered because there is no indication that emergency treatment was rendered within 48 hours following the onset of acute medical symptoms.

相关的规定

第三条. A. (2)(a) of the 雇主 Benefit Plan provides:

(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 an accident.

第三条. A. (3)(i) of the 雇主 Benefit Plan states:

(i) 紧急救治

当由医生提供时, benefits are provided for a Beneficiary who receives outpatient emergency medical treatment or treatment of an injury as a 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)和第三条. A. (3)(i) of the 雇主 Benefit Plan provide that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.

急诊室的记录 indicates that the patient’s symptoms were related to a mild throat infection which the emergency room physician diagnosed as sinusitis. Although the 员工’s spouse states that mild chest pains associated with the cold symptoms prompted her visit to the emergency room, there is no documentation of a complaint of chest pain in the physician’s emergency room record, nor does the record indicate that the 员工’s medical symptoms had become acute or changed within the preceding 48 hours. 急诊室的记录, as well as the fact that the emergency room visit lasted only 15 minutes, indicate that the physician concentrated on evaluating the spouse’s complaint of “chills, 全身疼痛, 喉咙痛, 还有上周的头痛,而不是轻微的胸痛, a symptom never documented by the medical record nor evidenced by the performance of tests such as a chest x-ray, blood tests or an electrocardiogram.

Because the emergency room care sought by the patient was not prompted by the onset of acute medical symptoms and was not of an emergency nature, the 雇主 is not responsible for payment of the emergency room charge.

受托人的意见

The 雇主 is not responsible for the payment of the emergency room charge resulting from the 员工’s spouse’s visit on March 5, 1986.