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OPINION OF TRUSTEES ____________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

员工
雇主
02-042 - 2007年5月23日

在再保险

迈克尔W. 巴克纳,. 弗兰克·邓纳姆，迈克尔·H. Holland和Elliot A. 西格尔.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.

背景事实

Early April 5, 2006, at approximately 2:30 a.m., the Complainant’s spouse sought medical evaluation and treatment at a hospital emergency room (ER). ER records indicate the Complainant’s spouse reported sore throat symptoms and an inability to swallow, accompanied by a non-productive cough. Records indicate that the Complainant’s spouse’s throat had been sore for the preceding three-day period. 在急诊室, the Complainant’s spouse was treated by the emergency physician with injections of Rocephin, 一种抗生素, 和Decadron, 类固醇, and discharged approximately one hour later. The Respondent has denied benefits for the charges associated with the ER visit.

争端

Is the 雇主 required to provide benefits for the $503.00 in charges connected with the ER visit of the Complainant’s spouse on April 5, 2006?

双方立场

Position of the Complainant: The 雇主 is required to provide benefits for the $503.00 in ER charges incurred by the Complainant’s spouse on April 5, 2006, because her symptoms were acute and there was no other facility available at that time for treatment.

Position of the Respondent: The 雇主 is not required to provide benefits for the ER visit since the treatment was not rendered at an appropriate level of care, services could have been provided at a more appropriate setting, the Complainant’s spouse presented at the ER with non- urgent symptoms, and the treatment was not rendered within 48 hours following the onset of acute medical symptoms.

Opinion of Trustees ROD Case No. 02-042页2

Pertinent Provisions 第三条 A. (2) (a) of the 2002 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

第三条. A. (2) (a) of the 雇主 Benefit Plan provides benefits for emergency medical care when rendered within 48 hours following the onset of acute medical symptoms. EE records indicate that the Complainant’s spouse had a sore throat with difficulty swallowing for the preceding 3 days. 然而, a statement from the Complainant’s spouse indicates a sudden increase in her difficulty swallowing. A statement from her daughter, 注册护士, also confirmed the acuity and severity of her mother’s condition on the night of treatment. 的资金’ Medical Director has reviewed the medical records in this case and the above statements, and is of the opinion that her symptoms would cause her to seek emergency medical evaluation and care, and that the treatment given was consistent with the presence of an acute and severe condition. 因此, the RODs that the Respondent cited in support of denying ER benefits do not apply here because the condition of the Complainant’s spouse was acute and ER treatment was an appropriate level of care. 另外, the treatment was provided at a time when facilities other than the ER were not available. Consistent with the provisions of the 2002 雇主 Benefit Plan, the Respondent is required to provide benefits for the ER visit by the Complainant’s spouse on April 5, 2006.

受托人的意见

Consistent with the provisions of the 2002 雇主 Benefit Plan, the Respondent is required to provide benefits for the ER visit by the Complainant’s spouse on April 5, 2006.