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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 88-732 - 1993年12月10日

校董会: 迈克尔·H. Holland, Chairman; Thomas F. 康纳斯,受托人;
马蒂D. Hudson, Trustee; Robert T. 华莱士,受托人.

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

周日, 12月13日, 1992, the 员工 sought medical evaluation and treatment for his sixteen-year-old daughter at the emergency room of a local medical center after she awakened with swelling and severe pain in the vaginal area. The emergency room record indicates that the symptoms began one week prior to the visit. The emergency room physician called in a surgeon, who performed an incision and drainage (I & D)脓肿. The patient was given an antibiotic (Keflex), and instructed to follow-up with the surgical clinic in one week.

The 雇主 paid all other charges but denied benefits for the emergency department fee, stating that treatment was not received within 48 hours following the onset of acute medical symptoms.

争端

Is the 雇主 required to provide benefits for the emergency department charge resulting from the 员工’s daughter’s evaluation and treatment on 12月13日, 1992?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the emergency department charge incurred on 12月13日, 1992 because the daughter’s symptoms had become more severe within the preceding 24 hours.

Position of the 雇主: The 雇主 is not required to provide benefits for the emergency department charge resulting from the 员工’s daughter’s evaluation and treatment on 12月13日, 1992 because the problem had begun a week earlier, and the emergency record does not indicate an exacerbation of the symptoms, therefore the use of the emergency room was not required.

相关的规定

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

(2) 门诊医院福利

(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 provides benefits for emergency medical treatment when the care is rendered within 48 hours following the onset of acute medical symptoms. The emergency record indicates that the symptoms had been present for a week and makes no mention that they had become more severe in the preceding 48 hours. 员工, 在他的声明中, states that the morning of the hospital visit his daughter had awakened in severe pain.

A Funds’ medical consultant has reviewed the medical records in this case and stated that abscesses of this type may continue to enlarge and can become very painful in a 24 to 48 hour period if they enlarge rapidly. The consultant further stated that even though the abscess partially drained while the child was waiting to be seen, the abscess still needed to be surgically opened and drained. He also stated that these abscesses can be more difficult to manage than other abscesses. Due to the enlargement of the abscess and the increased pain within the 48 hours prior to the visit, the consultant is of the opinion that the emergency room visit on 12月13日, 1992, 在医学上是合适的. 因此, the Trustees find that the 雇主 is required to provide benefits for the emergency room fee incurred by the 员工’s daughter on 12月13日, 1992.

受托人的意见

The 雇主 is required to provide benefits for the emergency room fee incurred by the 员工’s daughter on 12月13日, 1992.