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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: 88-130——1989年6月27日

Board of Trustees: 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

The 员工’s six-year-old daughter was taken to a hospital emergency room on Sunday, 7月3日, 1988 because she had a high fever. 最初, the 雇主 denied the charge related to the use of the emergency room for the six-year-old child but later provided coverage for it.

The 员工’s eight-year-old daughter was also taken to the emergency room on 7月3日, 1988 with her six-year-old sister. According to the emergency room record, the 员工’s spouse was concerned that the eight-year-old daughter “sounds congested” and that she might develop a fever like her sister’s. The eight-year-old had an oral temperature of 98.70. She was diagnosed as having a viral syndrome and discharged with instructions to follow up with her family physician, 如果有必要的话. The 雇主 denied the charge related to the use of the emergency room for the 员工’s eight-year-old daughter.

争端

Is the 雇主 required to pay the emergency room charge resulting from the 员工’s eight-year-old daughter’s evaluation and treatment on 7月3日, 1988?

双方立场

Position of the 员工: The 雇主 is required to pay the emergency room charge resulting from the 员工’s eight-year-old daughter’s evaluation and treatment on 7月3日, 1988, because emergency treatment was needed.

Position of the 雇主: The 雇主 is not required to pay the emergency room charge because the evidence does not indicate that the 员工’s eight-year-old daughter’s medical symptoms were acute.
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.

The emergency room record indicates that the 员工’s eight-year-old daughter was afebrile. A Funds’ medical consultant has reviewed the clinical information presented in this case and has advised that there is no documentation of any symptoms or illness that would require emergency treatment. The consultant advises there is no evidence that treatment was rendered for acute medical symptoms in this instance. Because there is no evidence of the existence of acute medical symptoms, the Trustees find the 雇主 is not required to pay the emergency room charge.

受托人的意见

The 雇主 is not required to pay the emergency room charge resulting from the 员工’s eight-year-old daughter’s evaluation and treatment on 7月3日, 1988.