受托人的意见
争议的解决
情况下没有. 88-398
第1页 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

在再保险

投诉人:被投诉人:ROD案件编号:

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.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, 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 private room charges for an 员工’s spouse under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse began to have problems with her back after a lifting incident in June 1990. She was subsequently treated with medication and underwent physical therapy to alleviate the pain. 1990年9月, the 员工’s spouse was seen by a neurosurgeon for complaints of severe pain in her left hip and leg and weakness upon walking. After examination, the neurosurgeon diagnosed the 员工’s spouse as having a herniated disc.

雇员的配偶从11月8日起住院, 1990年至11月20日, 1990 for a Computerized Tomography (CT) scan and a Magnetic Resonance Imaging (MRI) of the lower spine and a hemilaminotomy (surgical removal of a ruptured disc). 雇员说他的配偶在11月10日被转移到一个私人房间, 1990年，因为她的病情. 雇员说当她被转移后他们和神经外科医生谈话时, 他同意私人病房在医疗上是必要的. 雇员配偶的神经外科医生在一封日期为3月15日的信中表示, 1991, that the 员工’s spouse was placed in a private room during her hospitalization in November 1990 because of extreme anxiety and nervousness. 他说，另一个人和她在同一个房间里会使她的处境更糟.

The 雇主 provided benefits for the room and board charges for the entire hospitalization at the semi-private rate. 雇主拒绝支付私人房间的额外费用.

争端

员工
雇主
88-398——1991年7月25日

受托人解决争议意见. 88-398
第二页

Is the 雇主 required to pay the full charges for a private room during the 员工’s spouse’s hospitalization from November 10, 1990年至11月20日, 1990?

双方立场

Position of the 员工: The 雇主 is required to pay the full charges for a private room during the 员工’s spouse’s hospitalization because her physician agreed that she should have been placed in a private room because of her extreme anxiety and nervousness.

Position of the 雇主: The 雇主 is not required to pay the full charges for a private room during the 员工’s spouse’s hospitalization because the 员工’s spouse’s condition did not require isolation for her own health or for that of others and there is Insufficient medical documentation to establish that a private room was medically necessary.

相关的规定
雇主福利计划第三条的引言部分规定:

第三条-福利

Covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or Injury and which are given at the appropriate level of care, 或计划另有规定. The fact that a procedure or level of care Is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under this Plan.

第三条. A. 雇主福利计划(1)(c)规定:(1)住院病人福利

(c)私人房间

被关在单独的房间里, benefits will be provided for the hospital’s most common charge for semi-private room accommodations and the Beneficiary shall be responsible for any excess over such charge except that private room rates will be paid when (I) the Beneficiary’s condition requires him to be isolated for his own health or that of others, or (ii) the hospital has semi- private or less expensive accommodations but they are occupied and the Beneficiary’s condition requires immediate hospitalization. 半私人房间价格, 非私人房费, will be paid beyond the date a semi-private room First becomes available and the Beneficiary’s condition permits transfer to those accommodations.

受托人解决争议意见. 88-398
第3页

第三条. A. (11)(a) 10. 雇主福利计划规定:(11)一般除外事项

(a)除了《皇冠搏彩中心》中另有规定的具体除外事项之外, 以下情况也不提供福利:

10. 私人房间禁闭的费用，但平面图中特别说明的除外.

讨论

The Introduction to 第三条 of the 雇主 Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary for the diagnosis or treatment of an illness or injury and which are given at the appropriate level of care, 或计划另有规定. 第三条. A. (1)(c) of the Plan provides benefits for a private room when a Beneficiary’s condition requires isolation for his own health or that of others, or when a Beneficiary requires immediate hospitalization and all semi-private or less expensive accommodations are occupied. 第三条. A. (11)(a) 10. 雇主福利计划中指出，私人房间限制收费, 除非计划中有特别说明, 被排除在保险范围之外.

在这种情况下, 该雇员的配偶于11月8日住院, 并于11月10日被转移到一个私人房间, 1990. Although the 员工’s spouse’s physician later stated that sharing a semi-private room would have aggravated the 员工’s spouse’s extreme anxiety and nervousness, there is no indication that the physician ordered the private room and the physician has not stated that a private room was medically necessary or required for the patient’s own health or that of others. A皇冠搏彩中心网站的医疗顾问审查了此案, 包括雇员配偶的神经外科医生的信和医院记录. The consultant advises that the medical documentation provided does not establish that isolation in a private room was required for the patient’s own health or for that of others, 或者在住院期间需要一个单独的房间. Because it has not been established that the private room charges in this case were incurred under the circumstances described in 第三条. A. (1)(c), the private room charges in excess of the semi-private room rate are not covered under the terms of the 雇主 Benefit Plan.

受托人的意见

The 雇主 is not required to pay the full charges for a private room during the 员工’s spouse’s hospitalization from November 10, 1990年至11月20日, 1990.