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OPINION OF TRUSTEES ____________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

在再保险

员工
雇主
11-0006 - 2013年3月27日

迈克尔·H. 荷兰，丹尼尔·L. Fassio和Marty D. 哈德逊

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

The Complainant’s spouse sought medical treatment at the local emergency room on March 25, 2012, complaining of pain and swelling of the right knee, accompanied by red streaks that Complainant’s spouse believed indicated an infection of the knee. Respondent denied the emergency room charges, stating that the patient admitted to having right knee pain for the previous two weeks and the diagnosis code indicated a non-emergency condition.

争端

Is Respondent required to provide benefits for Complainant’s spouse’s emergency room visit on March 25, 2012?

双方立场

Position of the Complainant: The Complainant’s spouse experienced acute symptoms indicating a possible infection of the knee, and utilized the Emergency Room within 24 hours of the onset of the pain, swelling and signs of infection in the right knee. The charges are a covered benefit as provided for in the 雇主 Benefit Plan.

Position of the Respondent: The patient had a painful and swollen knee for two weeks, with no indication that her primary physician had been contacted. 另外, there is no indication that the level of pain increased over the two week period prior to the time she sought treatment in the emergency room, and the discharge diagnosis indicated she was treated for a non-emergency condition.

Opinion of Trustees ROD Case No. 11-0006第二页

Pertinent Provisions 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

第三条.A(2)(a) of the 雇主 Benefit Plan provides benefits for emergency medical treatment if the emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms. 的资金’ Medical Director reviewed the file, including the emergency room records, and determined that the acute medical symptoms reported by Complainant’s spouse, specifically the manifest indications of a possible knee infection, had an onset of less than 48 hours prior to Complainant’s spouse’s receipt of emergency room treatment. 因此, because the acute medical symptoms began less than 48 hours prior to the time Complainant’s spouse sought treatment at the emergency room, the charges associated with the emergency room visit are a covered benefit under the terms of the 雇主 Benefit Plan.

Coverage under the 雇主 Benefit Plan is not limited to treatment for life-threatening emergencies, as suggested by the Respondent, and the Funds’ Medical Director noted that Respondent’s consideration of non-emergent diagnosis discharge codes as the basis for determining the medical necessity or appropriateness of coverage of emergency medical treatment under the 雇主 Benefit Plan is not consistent with the terms, provisions and requirements of the 雇主 Benefit Plan.

受托人的意见

根据第三条.A(2)(a) of the 雇主 Benefit Plan, Respondent is required to provide benefits for Complainant’s spouse’s emergency room visit on March 25, 2012.