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受托人的意见
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在再保险
发牢骚的人 : 养老金领取者
被调查者 : 雇主
ROD案例编号:88-763 - 1995年6月23日
受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，马蒂·D. 哈德逊和
罗伯特T. 华莱士.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for home health care under the terms of the Employer Benefit Plan.
背景事实
多种医疗问题, the Pensioner had been receiving home health care 24 hours a day, 从12月开始每周7天, 1992. 他于1993年8月31日去世. According to medical records and nursing notes provided in this case, he was an insulin-dependent diabetic who suffered from chronic renal (kidney) failure, severe peripheral vascular disease (a disease effecting the copious blood supply to the vessels situated away from the center or central structure [trunk of the body]), chronic cor pulmonale (heart disease due to pulmonary hypertension secondary to disease of the blood vessels of the lungs), 煤矿工人尘肺病(黑肺病), and neutropenia (a decrease in the number of neutrophilic leukocytes in the blood). The Pensioner had numerous hospitalizations for recurrent problems including pneumonia and chronic draining ulcers of his lower extremities.
家庭保健服务包括糖尿病检测, 协助药物和胰岛素注射, 腿部溃疡的伤口护理, and assistance with activities of daily living such as bathing and meal preparation. 根据所提供的信息, 领取养老金的人在没有帮助的情况下走动, 能自己解决上厕所的问题, and capable of injecting his insulin and performing his own medical tests. The home health care had been delivered by nurses and nurses aides on an 不间断的基础. The Employer stated that this type of nursing service constituted private duty care and, 像这样, 不是雇主福利计划所涵盖的福利.
争端
Was the Employer required to continue to provide benefits for 24 hour-per-day, seven day a week home health care as had been delivered to the Pensioner since 1992?
双方立场
Position of the Pensioner: The Employer was required to provide benefits for the 24 hour-a-day, seven days a week home health care because such care was medically necessary.
Position of the Employer: The Employer was not required to provide benefits for the 24 hour-a-day, seven days a week home health care since this constituted private duty nursing care and, 像这样, 不是保险福利吗.
相关的规定
第三条.A.雇主福利计划的(6)(a)和(c)条款规定:
(6)家庭健康服务 & 设备
(a)总则
为家庭保健服务提供福利, including nursing visits by registered nurses and home health aides, 以及各种康复疗法, subject to the following conditions and approval of the Plan Administrator.
1. 受益人必须接受医生的治疗.
2. The Beneficiary’s medical condition must require skilled nursing care, 物理治疗, 或者每60天至少进行一次语言治疗.
3. The physician must initiate a treatment plan and specify a diagnosis, the Beneficiary’s functional limitations and the type and frequency of skilled services to be rendered.
4. 受益人必须待在家中. The services must be provided by a certified home health agency.
(c)熟练护理
Benefits are provided for skilled nursing care rendered by a registered nurse as a home health service when a Beneficiary’s condition has not stabilized and a physician concludes that the Beneficiary must be carefully evaluated and observed by a registered nurse. The Plan Administrator may request an evaluation visit to the Beneficiary’s home.
第三条.A.(11)(a) 7. 和8. 状态:
(11) 一般的除外
(a) In addition to the specific exclusions otherwise contained in the Plan, 以下情况也不提供福利:
7. 私人值班护理. If necessary to preserve life and certified as medically necessary by the attending physician and an Intensive Care Unit is unavailable, benefits are provided for private duty nursing services for up to 72 hours per inpatient hospital admission. In no event will payment be made for private duty nursing during a period of confinement in the Intensive Care Unit of a hospital.
8. 监护、康复或休养治疗.
讨论
根据第三条.A.(6)(a)雇主福利计划, benefits are provided for home health services by nurses and nurses aides on an intermittent basis. 根据第三条.A.(11) 7. 每天24小时不提供福利, seven day per week care unless the Beneficiary is confined in a hospital and the nursing care is being given in lieu of confinement in the Intensive Care Unit. 第三条.A.(11) 8. 不包括监护福利.
ROD 84-283(附件副本), the Trustees denied benefits for private duty nursing at home, stating that the home health services contemplated in 第三条.A.(6)(a) consist of visits by registered nurses and home health aides to provide certain specific services on an intermittent basis. 提供连续的护理服务, 不间断的基础, 如ROD 84-283和此处所述, 构成私人值班护理. 根据第三条.A.(11) 7., private duty nursing is excluded from coverage except when provided in an inpatient setting as noted above.
A Funds’ medical consultant has reviewed the evidence submitted in this case and has determined that the care delivered was custodial in nature, was mainly to help the Pensioner with his activities of daily living and to assist with his medications, 注射, 还有穿衣的变化. The consultant further noted that the home health service records document that the
care delivered to the Pensioner was not skilled in nature nor oriented toward teaching the patient, 或者他的家人, 自我护理方法. Since the home health care services provided to the Pensioner constitute custodial and around-the clock care, the Trustees find that these services are not eligible under the terms of the Employer Benefit Plan.
受托人的意见
Consistent with the provisions of the Employer Benefit Plan, the Employer is not required to provide benefits for the home health care provided to the Pensioner.