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OPINION OF TRUSTEES _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

受托人:

在再保险

员工
雇主
88-849 - 1996年3月6日

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 inpatient detoxification under the terms of the 雇主 Benefit Plan.

背景事实

The 员工 and his spouse were involved in an automobile accident in 1988 that left the 员工 with residual pain and his spouse approximately three-quarters paralyzed. The record states that his wife blames the 员工 for her medical condition although it is not clear that he was at fault in the accident. The 员工 states that her attitude augmented his depression and feelings of guilt, 导致他增加了酒精摄入量.

7月9日, 1991, the 员工 sought help from his 雇主’s 员工 Health Advisory Program (EHAP) citing his depression and increasing alcohol consumption. 他被建议第二天到EHAP报到. 在那里咨询后, he was referred to an area hospital where he was admitted to the inpatient detoxification unit. 那天晚上, a routine detoxification regimen was begun following a telephone order from his physician. (The telephone order was signed by the 医生tor the following day.) He also received treatment and diagnostic studies for his chronic leg pain and depression. 入院后9天, he was transferred to a comprehensive medical unit for continued treatment of his severe depression.

The 雇主 has provided benefits for the inpatient stay related to the 员工’s depression, 但一直否认为排毒停留带来的好处, 声明这不是紧急入院.

争端

Is the 雇主 required to provide benefits for the 员工’s admission to the inpatient detoxification unit?

双方立场

受托人的意见
连杆箱编号. 88-849
第二页
Position of the 员工: The 雇主 is required to provide benefits for the inpatient admission for detoxification because the admission was medically necessary.

Position of the 雇主: The 雇主 is not required to provide benefits for the inpatient admission for detoxification because the admission was not an emergency.

相关的规定
The Introduction to 第三条 of the 雇主 Benefit Plan states, in pertinent part:

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. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. . . . Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this 第三条.

第三条 (A) (1) (f) states: 第三条 Benefits

A. 健康的好处
(1)住院医疗福利

(f)酗酒和滥用药物

Benefits are provided for a Beneficiary who requires
emergency detoxification hospital care for the treatment of alcoholism or emergency treatment for drug abuse. Such treatment is limited to 7 calendar days per inpatient hospital admission.

讨论

受托人的意见
连杆箱编号. 88-849
第3页
The Introduction to 第三条 limits covered services to those services that are reasonable and necessary for the treatment of an illness or injury and are given at the appropriate level of care. 第三条. A. (1) (f) provides that inpatient hospitalization for emergency detoxification for the treatment of alcoholism is a covered service, but limits the coverage to a length of stay of seven calendar days per inpatient hospital admission for this treatment.

A Funds’ medical consultant has reviewed the medical records for the inpatient period from July 10 to 19, 1991 and has concluded that the 员工’s admission to the hospital unit for detoxification was medically appropriate. 因此, the 雇主 is required to provide benefits for seven of the nine days the 员工 was in the detoxification unit. 在剩下的两天监禁期间, the 员工 incurred charges of $820 for room and board and $32.10美元用于药物治疗. The 雇主 is not required to provide benefits for room and board of $820, 但需要提供32美元的福利.10美元用于药物治疗, since these would have been medically appropriate regardless of the setting and are not affected by the seven-day inpatient treatment limitation.

受托人的意见

The 雇主 is required to provide benefits for seven of the days the 员工 was an inpatient in the detoxification unit, is not required to provide benefits for room and board ($820.00) for the remaining two days but is required to provide benefits medications ($32.10) incurred in that period, since these would have been used regardless of the setting.