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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: 88-412 - 1991年10月22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, 受托人已经审查了这一争议的事实和情况，该争议涉及根据雇主福利计划条款为医生助理的服务提供福利.

背景事实

The 员工’s spouse was operated on as an outpatient for carpal tunnel syndrome of the right hand on October 4, 1990, and for carpal tunnel syndrome of the left hand on November 10, 1990. The syndrome is a complex of symptoms resulting from nerve compression, with pain and burning or tingling in the fingers and hands. 在两次行动中, the neurosurgeon who performed the surgery was assisted by a physician’s assistant.

The 雇主 provided coverage for the services of the neurosurgeon and associated hospital costs. The 雇主 denied coverage for the services of the physician’s assistant, 声明只有当受益人是住院病人，并且受益人的状况和手术服务类型需要这种援助时，助理外科医生的服务才被纳入雇主福利计划. 雇主也拒绝让受益人免受外科医生试图收取医师助理服务费用的伤害.

争端

雇员配偶进行两次腕管综合症手术期间，外科医生试图收取医生助理的费用，雇主是否需要保护雇员免受其害?

双方立场

雇员的立场:雇员要求雇主保护他不受神经外科医生收取雇员妻子因腕管综合症进行的两次手术期间使用医生助理的费用的影响.

雇主的立场:雇主不负责使雇员免受伤害，因为在门诊手术中使用助理外科医生不在雇主福利计划的承保范围内, 此外, 该名外科医生已获支付超过其就腕管综合症手术所提供服务的合理及惯常收费.

相关的规定

The Introduction to 第三条 的“雇主福利计划”规定:

第三条-福利

承保的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内. In determining questions of reasonableness and necessity, due consideration will be given to the customary practices of physicians in the community where the service is provided. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, and accordingly this paragraph shall not be construed to detract from plan coverage or eligibility as described in this 第三条.

第三条. A. (3) (b)及(o) 4. 的“雇主福利计划”声明:

(3) Physicians’ Services and Other Primary Care

(b) 助理外科医生

If the Beneficiary is an inpatient in a hospital, 当受益人的情况和手术类型需要此类协助时，积极协助手术医师执行此类手术服务的医生也将获得赔偿.

(o) Primary Medical Care – Miscellaneous

4. Benefits are provided for “physician extender” care or medical treatment administered by nurse practitioners, 医师助理或其他持证或有执照的保健人员，在医师的监督下提供此种服务.

第三条. A. (10)(g) 3. 的“雇主福利计划”规定:

(g) Explanation of Benefits (EOB), Cost Containment and Hold Harmless

3. 雇主和妇女协会一致认为，收费过高和保健费用不断上涨是一个共同问题，需要双方共同努力加以解决. In any case in which a provider attempts to collect excessive charges or charges for services not medically necessary, 如计划所界定, 来自受益人, the Plan Administrator or his agent shall, with the written consent of the Beneficiary, 试着解决这个问题, either by negotiating a resolution or defending any legal action commenced by the provider. 计划管理人或其代理人是否代表受益人协商事项的解决方案或为法律诉讼进行辩护, the Beneficiary shall not be responsible for any legal fees, 定居点, judgments or other expenses in connection with the case, but may be liable for any services of the provider which are not provided under the Plan. The Plan Administrator or his agent shall have sole control over the conduct of the defense, including the determination of whether the claim should be settled or an adverse determination should be appealed.

讨论

第三条. A. (3) (b) of the 雇主 Benefit Plan states that if a Beneficiary is an inpatient in a hospital, 当受益人的病情和手术类型需要这种帮助时，为积极协助手术医生进行手术服务的医生提供的服务将获得补偿. 在这种情况下，雇主拒绝为外科助理的服务提供福利，理由是这种服务只适用于住院手术, 如第三条所述. A. (3) (b). 但是，第三条. A. (3) (b) pertains to the services of an assisting physician, and the records in this case clearly indicate that the assistant was not a physician, 而是医生的助理. 第三条. A. (3) (b) is therefore not applicable to the facts in this case.

雇主福利计划第三条导言规定，所涵盖的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供. 第三条. A. (3)(o) 4. of the Plan provides benefits for physician extender care or medical treatment administered by nurse practitioners, 医师助理或其他持证或有执照的保健人员，在医师的监督下提供此种服务.

A Funds’ medical consultant has reviewed this case and has advised that the carpal tunnel procedures performed on October 4, 1990年11月10日, 1990 do not require the services of a physician’s assistant. 根据顾问的说法, 医院的外科门诊部通常配备适当的工作人员，使外科医生在没有额外助手的情况下完成手术. 咨询顾问指出，没有文件表明在本案中没有这类工作人员，也没有文件表明在本案中医生助理的服务在其他医疗上是必要的. Because the medical necessity of the physician’s assistant’s services has not been established, the 雇主 is not required to provide benefits for such services under the 雇主 Benefit Plan.

第三条. A. (10)(g) 3. 《皇冠搏彩中心网站》规定，计划管理人应尝试与试图收取非医疗必需服务费用的供应商进行谈判，或保护雇员免受其害. Whether the 雇主 negotiates a resolution or defends a legal action, the 员工 is not responsible for any expenses in connection with such charges, but may be liable for services that are not provided under the Plan. This is known as the Plan’s “hold harmless” provision.

The 雇主 has refused to hold the 员工 harmless in this case, stating that the use of an assistant for outpatient surgery is not a covered benefit under the 雇主 Benefit Plan. 然而, 如上所述, physician extender care rendered under the supervision of a physician is covered, unless it is deemed not medically necessary. Inasmuch as the use of a physician’s assistant in this case was not medically necessary, the 雇主 must hold the 员工 harmless.

受托人的意见

雇主必须保护雇员免受外科医生收取医师助理服务费用的影响，在这种情况下，这些费用在医学上是不必要的.