受托人的意见
争议的解决
情况下没有. 81-267
第1页 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

投诉人:被投诉人:ROD案件编号:

在再保险

员工
雇主
81-267——1983年9月27日

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. 迪恩,受托人.

Pursuant to Article IX of the United Mine Workers of America 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 payment of emergency room charges, and hereby render their opinion on the matter.

The issue of eligibility for 疾病及意外福利 was also raised in this dispute. 疾病及意外福利, as set forth in Article XI of the 1950 Benefit Plan and Trust, are beyond the authority of the exemption granted to the Trustees by the Department of Labor and, 因此, 无法解决.

背景事实

根据提交的信息, the 员工 experienced episodes of “numbness on and off” for approximately one week prior to his emergency room visit. 2月2日, 1983, he experienced an acute change in his condition when his left arm became “really cold and numb” and he began to experience “a big throbbing like pain” which radiated “up and down” his arm. Because of these new and acute symptoms he became concerned enough to seek medical attention. Since his personal physician’s office was closed, he sought care for those problems at the local emergency room. 雇主拒绝支付28美元.急诊室的费用是100美元.

争端
Is the 雇主 responsible for payment of emergency room charges?

各方立场

Position of 员工: The emergency room charge should be a covered benefit since it was the only facility available for the evaluation of the acute medical symptoms he experienced.

受托人的意见 争议的解决 情况下没有. 81-267
第二页

Position of the 雇主: The emergency room charge is not covered because this case cannot be considered a valid emergency medical situation requiring emergency treatment, since his symptoms were no different than any experienced the previous week.

第三条有关规定. A.(2) (a) of the 雇主’s Benefit Plan provides:

Benefits are provided for a Beneficiary who receives emergency medical treatment or medical treatment of an injury aa 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.

1981 Question and Answer #81-10 provides:
Subject: Definition of Emergency Treatment Benefit
References: Amended 1950 and 1974 Benefit Plans and Trusts, Article III,

第A(2)及A (3) (i)条

问题:

Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident

1. Would emergency treatment for conditions such as the following be covered under this provision?
   • -痛风引起的急性疼痛?
   • –  heart attack, severe chest pain, or congestive failure experienced by a

     患有(慢性)心脏病的病人?

   • –  intracranial bleeding or stroke experienced by a patient with hypertension?
2. Are benefits provided for inpatient and outpatient hospital and physicians’ services following emergency treatment beyond the 48-hour initial care limit (for example, 拆除缝线或拆除石膏)?

答:

1. 是的, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic.
2. 是的, if the follow-up treatment is covered under the Plan.

受托人的意见 争议的解决 情况下没有. 81-267
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讨论

Q&第81-10条和第三条. A. (2) (a) of the 雇主’s Benefit Plan provide that for emergency medical treatment to be a covered benefit, it must be rendered within 48 hours following the onset of acute medical symptoms.

The information presented in this case establishes that the 员工 presented himself to an emergency room for evaluation of acute symptoms within 48 hours of their onset.

的资金’ medical staff reviewed the clinical information presented in this case. They are of the opinion that the 员工’s symptoms did justify emergency medical treatment and/or evaluation.

Because it has been determined that the patient’s condition did warrant emergency medical treatment and because the treatment was rendered within 48 hours of the onset of acute symptoms, the 雇主 is responsible for payment or the emergency room charges.

受托人的意见

The Trustees are of the opinion that the 雇主 is responsible for payment of the emergency room charges.