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OPINION OF TRUSTEES ____________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

员工
雇主
11-0100 - 2015年6月9日

在再保险

迈克尔·H. 霍兰德，马蒂·D. 迈克尔·哈德逊. 麦科恩和约瑟夫. Reschini

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

3月8日, 2013, the Complainant’s spouse sought treatment at the emergency department of the local hospital. The chief complaint was eye redness that started earlier the same day. She alleged that her primary care physician had retired and that she had not been able to secure an appointment with another physician. Complainant’s spouse was diagnosed with a skin rash, sent home with a topical antibacterial cream and advised to schedule a follow-up dermatology appointment.

The Complainant’s spouse visited the emergency department of a hospital on July 15, 2013, after a referral from an urgent care center. Her chief complaint was a right facial droop – with an onset of the same day as the emergency room visit – that she feared was a stroke. The Complainant’s spouse reported a previous insect bite and a skin rash and was diagnosed with Bell’s Palsy presumptively caused by Lyme disease. Later testing confirmed that she had contracted Lyme disease.

Respondent appears to have denied payment for both 急诊室就诊 based on the discharge diagnosis.

争端

Is Respondent required to provide benefits for Complainant’s spouse’s 急诊室就诊 on March 8, 2013, 7月15日, 2013?

Opinion of Trustees ROD Case No. 第2页

双方立场
Position of the Complainant: The charges are a covered benefit under the 雇主 Benefit Plan.

Position of the Respondent: No position was submitted by the Respondent.

Pertinent Provisions 第三条.A(2)(a) of the 雇主 Benefit Plan states:

第三条利益a. 健康的好处

(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 急诊室就诊 on March 8, 2013, 7月15日, 2013, met the timeliness and acuity requirements of the 雇主 Benefit Plan and that, 因此, the Respondent should be responsible for the emergency room expenses.

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, 规定, 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 the March 8, 2013, 7月15日, 2013, 急诊室就诊.