受托人的意见
争议的解决
情况下没有. 88-159
第1页 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

在再保险

员工
雇主
88-159——1990年1月16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

The 员工’s spouse has a chronic low white blood cell count, which makes her prone to serious infection. She developed a viral syndrome that persisted for several weeks and was unresponsive to treatment with different antibiotics. 周日, 1月22日, 1989, the 员工 called his spouse’s primary physician because she was “very ill.” The physician concluded that her condition could be symptomatic of a serious problem and advised that she should go to the emergency room immediately. According to the emergency room record, the 员工’s spouse complained of headaches, 腹部疼痛, 恶心想吐 and vomiting that had been persisting “on and off.” The 员工’s spouse underwent a battery of tests and was diagnosed with a viral syndrome. She was instructed to see her primary physician the following morning and was discharged.

The 雇主 denied the charge related to the use of the emergency room by the 员工’s spouse.

争端

Is the 雇主 required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on 1月22日, 1989?

双方立场

受托人的意见 争议的解决 情况下没有. 88-159
第二页

Position of the 员工: The 雇主 is required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on 1月22日, 1989 because the 员工’s spouse was very ill and emergency medical treatment was necessary.

Position of the 员工: The 雇主 is not required to pay the emergency room charge because emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms.

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

(2)医院门诊福利
(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 benefits for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms.

The 员工’s spouse had a viral syndrome that had persisted for several weeks and was unresponsive to treatment. On the day of the emergency room visit, the 员工’s spouse’s symptoms of headache, 腹部疼痛, 恶心想吐, and vomiting worsened to a degree that caused her primary physician to send her to the emergency room. A Funds’ medical consultant has reviewed the documentation in this file and advised that the patient’s symptoms were an acute exacerbation of the persistent viral syndrome. The medical consultant further advised that, because the patient’s immune system was compromised by a chronic low white blood cell count, such acute symptoms would reasonably indicate the need for emergency medical care to prevent serious complications. Inasmuch as emergency medical treatment was rendered within 48 hours after the patient developed acute medical symptoms, the 雇主 is required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on 1月22日, 1989.

受托人的意见

The 雇主 Is required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on 1月22日, 1989.