受托人的意见
连杆箱编号. 88-825
第1页 _____________________________________________________________________________
对受托人的看法 _____________________________________________________________________________
投诉人:被投诉人:ROD案件编号:
受托人:
员工
雇主
88-825 - 1995年7月12日
在再保险
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 inpatient hospital care under the terms 雇主福利计划的成员.
背景事实
5月20日, 1993, 雇员配偶因左面部无力及颈部淋巴结病住院, 持续上呼吸道感染. 患者在住院前6周切除了胆囊. 她是一名新诊断的糖尿病患者，并注意到她患有病态肥胖. 入院后不久, the patient developed right upper quadrant pain for which a consultation was requested to rule out possible cardiac complications. 她接受了静脉抗生素和呼吸喷雾器的治疗. 她的面部麻木和急性鼻窦炎由另外两名会诊医生诊治. 她于1993年5月25日出院.
雇主提供了5月20日、5月21日和5月22日的住院费用补贴，但拒绝支付700美元.半私人房间和伙食费$3,085.5月24日及25日的相关收费为94元, stating that the inpatient confinement during this period was 医学上没有必要 and the treatment could have been rendered in an outpatient setting with equal efficacy.
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年12月16日为后续协议生效之日, 1994.
争端
雇主是否须提供700元的福利.半私人房间和伙食费$3,085.1993年5月23日和24日的有关费用为94英镑?
双方立场
受托人的意见
连杆箱编号. 88-825
第二页
Position of the 员工: The 雇主 is required to provide benefits for the 员工’s spouse’s hospitalization on May 23 and May 24, 1990 because the 员工’s spouse’s physician stated that he kept her hospitalized due to the enlarged node. 如果雇主不提供利益，它应该使雇员免受伤害.
Position of the 雇主: The 雇主 is not required to provide benefits for the room and board charges incurred by the 员工’s spouse on May 23 and 24, 1993 because the services rendered could have been safely and adequately performed in an outpatient setting and were, 因此, 医学上没有必要.
相关的规定
《官方网站》第三条导言中有关部分指出:
第三条福利待遇
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. (1) (a)规定:第三条福利
A. 健康的好处
(1)住院医疗福利
(a)半私人房间
When a Beneficiary is admitted by a licensed physician (hereinafter “physician”) for treatment as an inpatient to an Accredited Hospital (hereinafter “hospital”), benefits will be provided for semi-private room accommodations (including special diets and general nursing care) and all medically necessary services provided by the hospital as set out below for the diagnosis and treatment of the Beneficiary’s condition.
第三条. A. (10)(g) 3. 声明:第三条福利
A. 健康的好处
(10)总则
受托人的意见，ROD个案编号. 88-825页
无害的
(g)利益解释(EOB)、成本控制和保留
3. The 雇主 and the UMWA agree that the excessive charges and escalating health costs are a joint problem requiring a mutual effort for solution. In any case in which a provider attempts to collect excessive charges or charges for services 医学上没有必要, 如计划所界定, 来自受益人, 计划管理人或其代理人应, 经受益人书面同意, 试着解决这个问题, 通过协商解决方案或为提供商发起的任何法律诉讼进行辩护. Whether the Plan Administrator or his agent negotiates a resolution of a matter or defends a legal action on a Beneficiary’s behalf, 受益人不承担任何法律费用, 定居点, 与案件有关的判决或者其他费用, 但可能对提供商在本计划项下未提供的任何服务负责. 计划管理人或其代理人应全权控制答辩的进行, including the determination of whether the claim should be settled or an adverse determination should be appealed.
讨论
雇主是1988年工资协议的签署人. The 雇主 signed an Interim Agreement extending the terms and conditions of employment of the 1988 Wage Agreement from February 2, 1993年12月16日为后续协议生效之日, 1993. 这一争端的起因是在《官方网站》所涉期间发生的一件事.
The Introduction to 第三条 雇主福利计划的成员 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. The Introduction further states that the fact that a level of care is prescribed by a physician does not mean that it is medically reasonable or necessary or that it is covered under the Plan.
A Funds’ medical consultant has reviewed the information submitted and noted that any diagnostic evaluation(s) done during the last two days of hospitalization could have been scheduled on an outpatient basis since neither emergent results nor acute medical observation was required at this stage of the patient’s treatment and evaluation. The consultant has concluded that the documentation does not support the medical necessity for hospitalization on May 23 and 24, 1993. 因此, 根据雇主福利计划的规定, the 雇主 is not required to provide benefits for the inpatient hospitalization charges incurred during these two days, 但是需要为诊断测试提供益处, medications or any other charges which would have been incurred at a lower level of care as an outpatient.
受托人的意见，ROD个案编号. 88-825页
第三条. A. (10)(g) 3. 雇主福利计划的成员, 这就是所谓的“保持无害”条款, applies when provider charges are deemed to be excessive or when the services provided are 医学上没有必要. 经确定，该雇员的配偶本可以在1993年5月23日被解雇. 因此, 从医学角度看，没有必要再住院两天, and the 雇主 must hold the 员工 harmless from any attempts by the hospital to collect for the room charges for the final two days of hospitalization.
受托人的意见
The 雇主 is not required to provide benefits for the room and board charges for the 员工’s spouse’s hospitalization on May 23 and 24, 1993, 但须为当日产生的附属收费提供福利. The 雇主 should implement its hold harmless procedures as required under the provisions of 第三条.A.(10)(g) 3. 雇主福利计划的成员 in the event the hospital attempts to collect for the room charges for the final two days of hospitalization.