______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 88-813 - 1995年12月6日

受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，马蒂·D. 哈德逊和
罗伯特T. 华莱士.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

1993年7月28日凌晨1点47分.m. the 员工’s spouse sought medical evaluation and treatment in the hospital emergency room, complaining of frequent urination and back pain that had been present for two days. The emergency room nurses’ notes indicate that the patient stated that she had a history of urinary tract infections. The emergency room record further indicates that the patient’s vital signs were within normal limits.

After obtaining the results of a urinalysis, the emergency room physician diagnosed the 员工’s spouse’s condition as dysuria (painful urination), 处方药物, advised the patient to increase fluid intake, and to follow up with her personal physician the next day, 7月29日, 1993.

The 雇主 has stated that benefits have been provided for the physician charges in connection with the visit. The 雇主 denied benefits for $203 for the emergency room, including $68 for the use of the emergency room, $18 for medical-surgical supplies and $117 for laboratory charges.

The 雇主 was signatory to the 1988 National Bituminous Coal Wage Agreement
(Wage Agreement) which terminated February 1, 1993. The 雇主 signed an Interim Agreement extending the terms and conditions of employment of the l988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1994.

争端

Is the 雇主 required to provide benefits for the $203 in charges connected with the emergency room visit of the 员工’s spouse on July 28, 1993?

双方立场

Position of the 员工: The 雇主 is required to provide benefits for the $203 in emergency room charges incurred by the 员工’s spouse on July 28, 1993, 因为她的症状很严重, 需要紧急护理.

Position of the 雇主: The 雇主 is not required to provide benefits for the $203 in emergency room charges incurred by the 员工’s spouse on July 28, 1993, because there is no evidence that her symptoms were acute and required emergency medical treatment, 病人自己也承认, the symptoms had been present for two days prior to the emergency room visit.

相关的规定

第三条. A. (2) (a)雇主福利计划 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

The 雇主 was signatory to the 1988 Wage Agreement. The 雇主 signed an Interim Agreement extending the terms and conditions of employment of the 1988 Wage Agreement from February 2, 1993 to the effective date of a successor agreement on December 16, 1993. This dispute arose over an event that took place during the period covered by the Interim Agreement.

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

A Funds’ medical consultant has reviewed the medical records in this case and notes that the patient had complained of dysuria for two days prior to the emergency room visit. 另外, the consultant advises that the medical record does not indicate any severe, 或者急性恶化, the 员工’s spouse’s symptoms requiring emergency medical care. The consultant is of the opinion that the 员工’s spouse’s emergency room visit on July 28, 1993, 在医学上是不合适的, and that the patient could have received appropriate treatment at a lower level of care.

Because there is no evidence that new or increasingly severe acute medical symptoms occurred within 48 hours of the 员工’s spouse’s emergency room visit, the Trustees conclude that the 雇主 is not required to provide benefits for the $68 emergency room charge incurred on July 28, 1993, but is required to provide benefits for the $18 medical supplies and $117 laboratory charges.

受托人的意见

Consistent with the provisions of the 雇主 Benefit Plan, the 雇主 is not required to provide benefits for the emergency room charge incurred by the 员工’s spouse on July 28, 1993, but is required to provide benefits for the medical-surgical supplies and laboratory charges incurred on that date.