Opinion of Trustees
Resolution of Dispute
Case No. 88-208
第1页 ______________________________________________________________________________

对受托人的看法 ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

In Re

Employee
Employer
88-208 – February 28, 1990

Board of Trustees: Joseph P. Connors, Sr., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. Pierce, Jr., Trustee; Thomas H. Saggau, Trustee.

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, 受托人已经审查了根据雇主福利计划条款提供私人房间福利的争议的事实和情况.

Background Facts

The Employee’s spouse was hospitalized from April 27, 1988 to June 8, 1988 and from June 20, 1988 to July 13, 1988, the date of her death, for the treatment of rectal carcinoma. 雇员配偶的医生在3月29日的信中说, 1989, 雇员的配偶在两次入院期间都需要一个私人房间. He states that she was on an epidural morphine pump program, 有肠梗阻和骨髓抑制(骨髓产生血细胞和血小板减少)的证据, and required antibiotics and chemotherapy.

雇主拒绝在两次入住期间支付私人房间的额外费用, 指出没有医学证据证明雇员配偶的病情需要她为自己或他人的健康隔离, and there is no indication that a semi-private room was unavailable. The Employer paid for the room charges at the semi-private rate.

Dispute

雇员配偶从4月27日起住院期间，雇主是否须为其提供私人病房福利, 1988 to June 8, 1988 and from June 20, 1988 to July 13, 1988?

Positions of the Parties

Opinion of Trustees Resolution of Dispute Case No. 88-208
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雇员的立场:雇主必须支付私人房间的全部费用，因为雇员配偶的医生已经表示，私人房间是医疗上必要的.

雇主立场:由于雇员配偶的身体状况不符合第三条规定的包间要求，雇主不需要支付包间的全部费用. A. (1)(c) of the Employer Benefit Plan.

Pertinent Provisions
雇主福利计划第三条的引言部分规定:

Article III–Benefits

承保的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内。.

Article III. A. 雇主福利计划(1)(c)规定:(1)住院病人福利

(c) Private Room

For confinement in a private room, 医院将为半私人房间住宿的最常见费用提供补贴，受益人应负责超出该费用的任何部分，但在以下情况下支付私人房间费用:(i)受益人因自身健康或他人健康需要隔离, 或(ii)医院有半私人或较便宜的住宿，但已被占用，且受益人的病情需要立即住院治疗. Semi-private room rates, not private room rates, 是否在半私人房间首次可用且受益人的条件允许转移到这些房间之后支付.

Article III. A. (11)(a) 10. of the Employer Benefit Plan states: (11) General Exclusions

(a)除了《皇冠搏彩中心网站》中另有规定的具体除外事项之外, benefits are also not provided for the following:

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10. 私人房间禁闭的费用，但平面图中特别说明的除外.

Discussion

雇主福利计划第三条导言规定，所涵盖的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在该计划范围内. Article III. A. (1)《皇冠搏彩中心网站》(c)规定，当受益人的病情需要为其自身或他人的健康隔离时，可提供私人病房福利, 或受益人需要立即住院，而所有半私人或较便宜的住宿都已住满.

尽管雇员配偶的医生已经声明雇员配偶需要一个私人房间, 没有提供雇员配偶需要私人房间的具体医疗理由. A Funds’ medical consultant has reviewed this case, including the letter from the Employee’s spouse’s physician. 咨询人说，没有足够的医疗文件证明雇员的配偶为了自己或他人的健康需要隔离在私人房间, 也不知道在这两次住院治疗中有哪一次是需要私人病房的. 因为雇员配偶的私人病房的医疗必要性尚未确定, 雇主不需要支付雇员配偶从4月27日起住院期间发生的私人房间费用, 1988 to June 8, 1988 and from June 20, 1988 to July 31, 1988.

Opinion of the Trustees

雇主不需要支付雇员配偶从4月27日起住院期间发生的私人房间费用, 1988 to June 8, 1988 and from June 20, 1988 to July 31, 1988.