Opinion of Trustees
Resolution of Dispute
Case No. 88-377
Page 1 _____________________________________________________________________________
对受托人的看法 _____________________________________________________________________________
Complainant: Respondent: ROD Case No:
In Re
Employee
Employer
88-377 – April 24, 1991
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, and under the authority of an exemption granted by the United States Department of Labor, 受托人审查了有关根据雇主福利计划条款为雇员配偶住院提供福利的争议的事实和情况.
Background Facts
1989年12月27日，雇员的配偶住院接受改良乳房根治术. The Employer precertified the Employee’s spouse’s inpatient stay for four days. According to the Employee’s spouse’s physician, a fifth day of hospital care was required because of wound drainage and poor healing. 雇主为所有证明有医疗必要的住院费用提供福利, but denied benefits for the last day’s room and board charge.
Dispute
从12月27日起，雇主是否需要支付雇员配偶住院最后一天的食宿费, 1989 to January 1, 1990.
Positions of the Parties
雇员职位:雇主需要支付食宿费用，因为雇员配偶的医生认为她有必要住院直到1月1日, 1990.
雇主职位:雇主不需要支付雇员配偶住院最后一天的食宿费，因为在此期间雇主提供了服务
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period could have been safely and adequately provided on an outpatient basis, and hospitalization was not medically necessary.
Pertinent Provisions
The Introduction to Article III of the Employer Benefit Plan provides:
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. 由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. In determining questions of reasonableness and necessity, 将适当考虑提供服务的社区医生的习惯做法. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, 因此，本款不得被解释为减损本条款III所述的计划覆盖范围或资格.
Article III. A. 《皇冠搏彩中心》(1)(a)的相关部分规定:(1)住院病人福利
(a) Semi-private room
当受益人被持牌医生(以下简称“医生”)作为住院病人在认可医院(以下简称“医院”)接受治疗时。, 补助金将用于半私人房间住宿(包括特殊饮食和一般护理)以及医院为诊断和治疗受益人的病情而提供的下述所有医疗必要服务.
Discussion
雇主福利计划第三条导言指出，所涵盖的服务应限于诊断或治疗疾病合理和必要的服务
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illness or injury and which are given at the appropriate level of care. 《皇冠搏彩中心》进一步指出，医生规定某种程度的护理并不意味着这在医学上是合理的或必要的，也不包括在该计划之内. Article III. A. 《皇冠搏彩中心》第(1)(a)款规定，如果受益人由医生入院, 补助金将用于支付医院为诊断和治疗受益人的病情而提供的房间住宿和医疗必要服务.
在这种情况下，雇主拒绝支付雇员配偶从12月27日起住院最后一天的食宿费用, 1989 to January 1, 1990. A Funds’ medical consultant has reviewed the information submitted in this case, including detailed medical records and letters from the Employee’s spouse’s physician. 咨询顾问指出，医生的病程记录没有提供继续住院的任何医疗理由，医生的信函也没有提供证明住院超过预先证明的四天的医疗文件. According to the consultant, 护理记录显示12月28日伤口没有引流, 1989 and that by December 29, 1989 the patient was ambulating and taking fluids by mouth; there was no indication of a fever or other signs of infection. Based on this information, 顾问的结论是，从医学角度看，住院的最后一天是没有必要的. Accordingly, 受托人认为，根据雇主福利计划的条款，雇主拒绝支付雇员配偶住院最后一天的食宿费是合理的.
Opinion of the Trustees
从12月27日起，雇主不需要支付雇员配偶住院最后一天的食宿费用, 1989 to January 1, 1990.