受托人的意见
争议的解决
情况下没有. 88-554
第1页 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

在再保险

Complainant: Respondent: ROD 情况下没有:

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Elliot A. 西格尔,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, 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

6月1日, 1991, the 员工 sought medical evaluation and treatment for nausea, 呕吐, and diarrhea at a hospital emergency room. The emergency record indicates that the patient also complained of dull aches, dizziness, and cramps. The emergency room physician diagnosed viral gastroenteritis and released the patient with orders to rest, 把液体, 注意清淡的饮食.

The employer denied benefits for the emergency room charge. 争端

Is the 雇主 required to provide benefits for the emergency room charge resulting from the 员工’s treatment on June 1, 1991?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the emergency room charge resulting from the 员工’s evaluation and treatment on June 1, 1991 because treatment was rendered within 48 hours of the onset of acute medical symptoms.

Position of the 雇主: The 雇主 is not required to provide benefits for the 员工’s emergency room charge because the 员工’s symptoms were not acute and the treatment rendered was not of an emergency nature.

员工
雇主
88-554 - 1992年7月29日

受托人的意见 争议的解决 情况下没有. 88-554
第二页

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

(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

第三条. A. (2) (a) of the 雇主 Benefit Plan provides that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.

A Funds’ medical consultant has reviewed this file and determined that the 员工’s emergency room visit on June 1, 1991 should be considered medically appropriate because the 员工’s history, as recorded by the emergency room 医生tor and the nurse, was consistent with the diagnosis of viral gastroenteritis, 哪些会引起急性症状.

拒绝利益, the 雇主 stated that the emergency room classified the 员工’s condition as “good” on the emergency room record, and that there were normal temperature readings and no evidence of acute symptoms. 的资金’ medical consultant has advised in previous opinions that the emergency room’s classification of good, 公平, or poor condition has no relevance for coverage determination. These are classifications used by the hospital staff to determine whether the patient needs care immediately, 几分钟内, or may wait up to an hour or more, 如果有必要的话. The classifications are in no way meant to evaluate the patient’s need for same day emergency care. 进一步, the consultant states that patients with viral gastroenteritis typically have normal vital signs and appear normal upon physical examination. These findings would not preclude the necessity of an emergency room visit.

因此, it is the opinion of the Trustees that the 员工’s emergency room visit on June 1, 1991年在医学上是合适的.

受托人的意见

The 雇主 is required to provide benefits for the emergency room charge incurred by the 员工 on June 1, 1991.