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对受托人的看法 _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
84-707——1990年1月16日

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

根据美国煤矿工人联合会(“UMWA”)1950年福利计划和信托的第九条, 并根据美国劳工部授予的豁免授权, 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

5月24日, 1987, 雇员的配偶到医院急诊室寻求医疗评估和治疗. 根据急诊室的记录, 该雇员的配偶自5月20日起便抱怨胸部感冒及充血, 1987年，抗生素并没有缓解. 雇员配偶的体温于1987年5月23日上升. 根据记录，病人的左肺先前已被切除. The emergency room physician diagnosed the 员工’s spouse’s condition as bronchitis and instructed her to take a decongestant cough medicine.

9月6日, 1987, 雇员的配偶到医院急诊室寻求医疗评估和治疗. 根据急诊室的记录, 该雇员的配偶一直髋骨疼痛, 下背, 左肋骨和左肩从8月30日开始, 1987. The emergency room physician ordered x-rays of the left hip and sacroiliac joint and diagnosed the 员工’s spouse’s condition as arthralgia (joint 疼痛) or neuralgia (nerve 疼痛), 给她安排了物理治疗给她开了镇定剂出院, 抗抑郁药和镇痛/抗焦虑药.

10月4日, 1987, 雇员的配偶到医院急诊室寻求医疗评估和治疗. 根据急诊室的记录, 雇员的配偶自九月二十七日起躯干出现痒疹, 1987. The emergency room physician diagnosed the 员工’s spouse’s condition as allergic dermatitis and instructed her to take an antihistamine, 停止使用可的松软膏并与她的私人医生联系.

11月11日, 1987, 该雇员到医院急诊室寻求医疗评估和治疗. 根据急诊室记录，雇员抱怨胸部不适

受托人解决争议意见. 84-707页

疼痛, 恶心和呕吐从那天就开始了, 根据记录, the patient had a medical history of orthostatic hypotension (drop in blood pressure with change in position) and was on cardiac medications. 急诊室的医生检查了病人，并与他的私人医生交谈. The emergency room physician instructed the patient to see his personal physician the following day for further workup and treatment.

雇主否认了有关四次使用急诊室的指控. 争端

Is the 雇主 required to pay the emergency room charges resulting from the 员工’s spouse’s emergency room visits on May 24, 1987, 9月6日, 1987年和10月4日, 1987年11月11日雇员急诊室就诊, 1987?

双方立场

Position of the 员工: The 雇主 is required to pay the emergency room charges for all four visits because the services were rendered within the guidelines for coverage under the 雇主 Benefit Plan.

Position of the 雇主: The 雇主 is not required to pay the emergency room charges for the 员工’s spouse’s visits on May 24, 1987, 9月6日, 1987年和10月4日, 1987 because in each instance medical treatment was not rendered within 48 hours of the onset of her symptoms.

The 雇主 is not required to pay the emergency room charge for the 员工’s visit on November 11, 1987年，因为他没有得到可视为紧急医疗的服务.

第三条有关规定. A. 雇主福利计划第(2)(a)条规定:

(2)医院门诊福利
(a)紧急医疗和事故案件

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

受托人解决争议意见. 84-707页

根据第三条. A. (2)(a)雇主福利计划, benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.

A Funds’ medical consultant has reviewed the clinical information pertaining to all four emergency room visits in question. 5月24日, 1987 emergency room record indicates that the patient had experienced symptoms of a chest cold and congestion since May 20, 1987年5月21日，他开始服用抗生素治疗上呼吸道疾病, 1987. The consultant advises that there should have been a significant improvement in her symptoms within 48 hours (by May 23, 1987), 但患者的体温在5月23日反而上升了, 1987. The consultant is of the opinion that the patient’s condition had worsened within 48 hours of the emergency room visit on May 24, 1987. 顾问进一步建议, 因为病人只有一个肺, her worsening respiratory problems constitute acute symptoms that would reasonably indicate the need for emergency medical care. Inasmuch as emergency medical treatment was rendered within 48 hours following the onset of acute medical symptoms, 受托人认为雇主必须支付5月24日发生的急诊室费用, 1987.

九月六日, 1987年的急诊室记录显示，雇员的配偶臀部疼痛, 下背, 肋骨和左肩在就诊前一周. The medical consultant advises that there is no indication of any increase in the intensity of the 疼痛 or any changes in the patient’s symptoms during the 48 hours preceding the emergency room visit. 咨询医生认为，病人的症状并非急性医学症状. Inasmuch as emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms, the Trustees find that the 雇主 is not required to pay the emergency room charge incurred on 9月6日, 1987.

10月4日, 1987 emergency room record indicates that the 员工’s spouse had had a pruritic (itchy) rash on her trunk for eight days prior to the visit. The medical consultant advises that there is no evidence of acute medical symptoms that would warrant emergency medical treatment in this instance. Inasmuch as emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms, the Trustees find that the 雇主 is not required to pay the emergency room charge incurred on October 4, 1987.

11月11日, 1987年的急诊室记录显示雇员抱怨胸痛, 那天早些时候就开始恶心和呕吐. 患者有直立性低血压史，正在服用心脏药物. The medical consultant is of the opinion that the emergency room visit in this instance was prompted by the onset of symptoms that were reasonably judged to be acute and emergency medical treatment was warranted to evaluate the seriousness of the patient’s condition and to prevent further complications. The 雇主 contends that the 员工 did not receive services that can be considered “emergency medical treatment.“然而, the emergency medical treatment provided in this instance consisted of the emergency room physician’s evaluation and referral for follow-up care. Inasmuch as emergency medical treatment was rendered within 48 hours following the onset of acute medical symptoms,

受托人解决争议意见. 84-707页

the Trustees find that the 雇主 is required to pay the emergency room charge incurred on November 11, 1987.

受托人的意见

The 雇主 is required to pay the emergency room charges resulting from the 员工’s spouse’s emergency room visit on May 24, 1987年11月11日雇员急诊室就诊, 1987. The 雇主 is not required to pay the emergency room charges incurred by the 员工’s spouse on 9月6日, 1987年和10月4日, 1987.