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OPINION OF TRUSTEES ____________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

养老金领取者
雇主
02-039 - 2007年5月1日

在再保险

迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. Holland和Elliot A. 西格尔.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实

The Complainant sought treatment from his physician for back pain. 大约一周后, 4月25日, 2005, the Complainant experienced severe pain in his back while attempting to get out of bed. Consequently, the Complainant contacted his physician’s office. He was informed that the physician was not currently in the office and it was unknown when the physician would be in the office. Subsequently, the Complainant went to the emergency room to receive treatment for his back pain.

Coverage for the emergency room charge was denied by the Respondent. 争端

Is the Respondent required to provide coverage for the Complainant’s visit to the emergency

我于2005年4月25日离开房间?

双方立场

Position of the Complainant: The Respondent is required to provide coverage for the Complainant’s visit to the emergency 我于2005年4月25日离开房间, because the Complainant was in severe pain and the Complainant’s physician was not available.

Position of the Respondent: The Respondent is not required to provide coverage for the Complainant’s visit to the emergency 我于2005年4月25日离开房间, because “there were other viable alternatives available that could have provided the appropriate level of care in keeping with the language and intent of the 雇主 Benefit Plan.” The Complainant’s physician “works with at least three other physicians in the same facility. Surely, one of them was available on that date to treat [the Complainant].” The Respondent states that its position is supported by ROD 78- 081.

受托人的意见，ROD个案编号. 02-039第2页

Pertinent Provisions 第三条A. (2) (a) of the 2002 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) provides emergency room benefits for treatment received within 48 hours of the onset of acute medical symptoms.

的资金’ Medical Director has reviewed the documentation submitted in this case and notes that the Complainant was experiencing stiffness of the lower back for one to two weeks prior to the sudden onset of the severe pain Monday April 25, 2005. According to the Medical Director, severe pain of the lower back can be caused by minor or serious abnormalities and requires an evaluation by a Physician. The emergency room physician did an evaluation to rule out problems that might require admission or surgical intervention including X rays of the lumbo-sacral spine.

The treating emergency room physician certified that the Complainant’s condition was an emergency. 1到10分, the Complainant was given a pain rating of 10/10–the maximum level–at discharge. The emergency room records document that the Complainant’s severe pain began that day. 的资金’ Medical Director has concluded that the severity of the Complainant’s pain of one day’s duration warranted evaluation in an emergency room department. Therefore, consistent with 第三条A. (2) (a) of the 2002 雇主 Benefit Plan, the Respondent is required to provide benefits for the emergency room charge for the Complainant’s visit 4月25日, 2005.

To support its position in this dispute, the Respondent referred to previous Trustee Opinions where coverage for emergency room charges was denied. 然而, disputes concerning coverage for an emergency room charge are reviewed on a case-by-case basis because each case must be evaluated on its own merits based on the evidence submitted.

受托人的意见，ROD个案编号. 02-039第3页

受托人的意见

符合第三条A款. (2) (a) of the 2002 雇主 Benefit Plan, the Respondent is required to provide benefits for the emergency room charge for the Complainant’s visit 4月25日, 2005.