______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-580——1988年10月21日

Board of Trustees: 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

The 员工 sought medical evaluation and treatment at a hospital emergency room at 11:53 a.m. 1987年5月7日. The emergency room record lists the 员工’s symptoms as dyspnea (labored respiration), 胸闷, a productive cough with blood in the sputum, 喉咙痛, 耳痛, fever and aching throughout his body. According to the record, the onset of symptoms was early that morning. The 员工 was diagnosed as having acute bronchitis. He was treated with an injection of an antibiotic, given a prescription for an oral antibiotic and released.

The 雇主 paid the hospital’s pharmacy charge, but denied the charge for the emergency room services, stating that the record does not indicate that the 员工s symptoms were acute and treatment was received during 医生tors’ normal office hours. The 雇主 states that an independent registered nurse reviewed the case and advised that the 员工’s symptoms are those of the common cold.

争端

Is the 雇主 responsible for payment of the emergency room charge resulting from the 员工’s evaluation and treatment or May 7, 1987?

双方立场

Position of the 员工: The 雇主 is responsible for payment of the emergency room charge resulting from the 员工’s evaluation and treatment 1987年5月7日 because such treatment was medically necessary.

Position of the 雇主: The 雇主 is not responsible for payment of the emergency room charge resulting from the 员工’s evaluation and treatment 1987年5月7日 because the 员工’s medical symptoms were not acute and aid not require emergency medical treatment.

相关的规定

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

(2) Outpatient Hospital Benefits

(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 are provided for a Beneficiary who receives emergency medical treatment provided such treatment is rendered within 48 hours following the onset of acute medical symptoms.

The emergency room record indicates that the onset of the 员工’s symptoms occurred during the morning of the emergency room visit 1987年5月7日. A Funds’ medical consultant has reviewed the clinical findings and has advised that there is no evidence of acute medical symptoms which would justify emergency medical treatment in this case. Because the emergency room care sought by the patient was not prompted by acute medical symptoms that were of an emergency nature, the 雇主 is not responsible for payment of the emergency room charge resulting from the 员工’s evaluation and treatment 1987年5月7日.

受托人的意见

The 雇主 is not responsible for payment of the emergency room charge resulting from the 员工’s evaluation and treatment 1987年5月7日.