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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: 88-822 - 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. 哈德森和罗伯特·T. 华莱士.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

The 员工’s spouse states that the 员工 had a sore throat for about two days prior to his emergency room visit. She further states that he worked an extra shift in a windy area the night before and that he could not swallow water when he got home. She says she was concerned that he would become dehydrated, and after calling two physicians, 他们的办公室都关门了, took the 员工 to the emergency room on October 23, 1993年中午前不久.

The 雇主 provided benefits for the physician’s charge, but denied benefits for the emergency room charge of $70.00, the laboratory charge of $44.00 and the pharmacy charge of $41.00.

The 雇主 was signatory to the 1988 National Bituminous Coal Wage Agreement
(Wage Agreement) which terminated February 1, 1993. The 雇主 signed an Interim Agreement extending the terms and conditions of employment of the l988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1994.

争端

Is the 雇主 required to provide benefits for the emergency room charge of $70.00, the laboratory charge of $44.00 and the pharmacy charge of $41.00?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the emergency room and associated charges incurred by the 员工 on October 23, 1993.

Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room and associated charges since the treatment was not rendered at an appropriate level of care, nor were acute medical symptoms present.

相关的规定

第三条A. (2) (a)规定:

第三条:福利

A. 健康的好处

(2) Outpatient Hospital Benefits

(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

The 雇主 was signatory to the 1988 Wage Agreement. The 雇主 signed an Interim Agreement extending the terms and conditions of employment of the 1988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1993. This dispute arose over an event that took place during the period covered by the Interim Agreement.

第三条A. (2) (a) of the 雇主 Benefit Plan provides benefits for emergency medical treatment when it is rendered within 48 hours of the onset of acute medical symptoms.

A Fund’s medical consultant has reviewed the emergency room records in this case and notes that the medical records contain no documentation of the patient’s inability to swallow. He notes that the records indicate that the patient had no fever and that his other vital signs (blood pressure, 等.)在正常范围内. 相应的, he is of the opinion that the treatment in the emergency room was not the appropriate level of care in this instance. 因此, under the provisions of the 雇主 Benefit Plan, the 雇主 is not required to provide benefits for the use of the emergency room, but is required to provide benefits for the laboratory and pharmacy charges incurred during the visit, since these would have been incurred in a visit at a lower level of care.

受托人的意见

Consistent with the provisions of the 雇主 Benefit Plan, the 雇主 is not required to provide benefits for the emergency room charges for the 员工’s visit on October 23, 1993, but is required to provide benefits for the laboratory and pharmacy charges.