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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 84-695——1989年4月19日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,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

9月12日, 1987, the 员工’s nine-year-old daughter was taken to a hospital emergency room for medical evaluation and treatment. According to the emergency room record, the 员工’s daughter complained of an ear ache, 喉咙痛, 和发烧. The record indicates the child’s symptoms had begun the previous day. The emergency room physician diagnosed the 员工’s daughter’s condition as pharyngotonsillitis, an inflammation of the throat and tonsils, and prescribed an antibiotic and decongestant.

1月31日, 1988, the 员工’s daughter was again taken to a hospital emergency room for evaluation and treatment. According to the emergency room record, the 员工’s daughter complained of an ear ache, 发热, 咳嗽, 还有胸部不适. The onset of the symptoms was recorded as the day of the emergency room visit. The emergency room physician diagnosed the 员工’s daughter’s condition as pharyngitis (a 喉咙痛) and an upper respiratory infection and prescribed an antibiotic and decongestant.

The 雇主 denied the charges related to the use of the emergency room for both visits.

争端

Is the 雇主 required to pay the emergency room charges resulting from the 员工’s daughter’s evaluation and treatment on September 12, 1987年和1月31日, 1988?

双方立场

Position of the 员工: The 雇主 is required to pay the emergency room charges for the September 12, 1987年和1月31日, 1988 visits because the 员工’s daughter needed emergency medical treatment.
Position of the 雇主: The 雇主 is not required to pay the emergency room charges for the September 12, 1987年和1月31日, 1988 visits because the 员工’s daughter did not exhibit acute medical symptoms requiring emergency medical treatment on either of the visits.

相关的规定

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

根据第三条. A. (2) (a) of the 雇主 Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.

A Funds’ medical consultant has reviewed the clinical information pertaining to both emergency room visits in question. 九月十二日, 1987 emergency room record indicates that the child had an inflammation of the throat and tonsils only. The consultant advises that no evidence suggests that the symptoms were severe enough to warrant emergency medical treatment.

1月31日, 1988 emergency room record indicates that the child had experienced ear ache, 发热, 咳嗽, 还有胸部不适. The consultant advises that the child’s symptoms did not include any acute respiratory symptoms that would require emergency medical treatment.

Because the 员工’s daughter did not suffer from acute medical symptoms on September 12, 1987年或1月31日, 1988, emergency treatment was not required on either visit to the emergency room.

受托人的意见

The 雇主 is not required to pay the emergency room charges resulting from the 员工’s daughter’s evaluation and treatment on September 12, 1987年和1月31日, 1988.