File Download: 81-430

Opinion of Trustees
Resolution of 争端
情况下没有. 81-430
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对受托人的看法 ______________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

在再保险

Employee
雇主
81-430 – March 26, 1984

Board of Trustees: Harrison Combs, Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.

根据美国联合煤矿工人1950年福利计划和信托皇冠搏彩中心网站第九条, 并根据美国劳工部授予的豁免授权, 受托人审查了这一关于支付急诊室费用的争议的事实和情况, and hereby render their-opinion on the matter.

Background Facts

雇员是在职矿工，有资格享受雇主福利计划规定的健康福利. 1983年12月18日，他在当地一家医院的急诊室接受治疗.

The Employee states that, 因为他“感觉很糟糕”，也因为他找不到医生, he went to the emergency room for treatment. 急诊室记录显示病人抱怨感冒症状, productive cough, and headaches which had become worse since 11:30 that morning. 显然，该雇员自1983年12月14日以来一直在接受这些问题的治疗. 在急诊室对员工进行评估的医生提供的诊断是亚急性病毒性鼻咽炎伴全鼻窦炎. 为该员工开了麻醉止痛药和减充血药作为治疗. The 雇主 has denied payment of the $45.00 emergency room charge.

争端

雇主是否负责支付雇员在12月18日的急诊费用, 1983?

Positions of the Parties
雇员职位:急诊室费用应被视为承保福利.

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雇主立场:不包括急诊室费用，因为雇员的投诉不被视为需要紧急治疗的紧急医疗情况, 以及雇员在出现症状后48小时内没有得到紧急护理.

Pertinent Provisions Article III A. (2) (a) of the 雇主’s Benefit Plan provides:

补助金提供给因事故受伤而接受紧急医疗或医疗的受益人, 但必须在出现急性医疗症状或发生事故后48小时内提供这种紧急医疗.

Question and Answer #81-10 provides:

Subject: Definition of Emergency Treatment Benefit

References:Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Sections A (2) (a) and A (3) (i)

Question:

为紧急医疗或因事故受伤的医疗提供津贴, 但须在出现急性医疗症状或事故发生后48小时内进行治疗.

  1. 这一规定是否包括对下列情况的紧急治疗:
    • –  acute pain attributed to gout?
    • –  heart attack, severe chest pain, 或(慢性)心脏病患者的充血性心力衰竭?
    • -高血压患者颅内出血或中风?
  2. 是否为超过48小时初始护理限制的紧急治疗后的住院和门诊医院以及医生服务提供福利(例如, suture removal or cast removal)?

答:

1. 是的, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic.

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2. 是的, if the follow-up treatment is covered under the Plan.

Question and Answer #81-85 provides:

Subject: Follow-up Care to Emergency Treatment

References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (2) Ca) and (3) (i)

Question:

  1. 受益人需要在48小时初始紧急护理限制之外提供紧急治疗的后续服务, and which are also rendered in an emergency room. 医疗费和急诊费是否都有补贴?
  2. 受益人需要急诊室治疗，并在出现急性症状后58小时内接受治疗. After the 48-hour period has expired the acute symptoms reappear. 如果受益人在急性症状重现后48小时内去急诊室接受治疗, 医疗费和急诊费是否都有补贴?

答:

  1. 在这种情况下，急诊室服务费不包括在内. 然而, 将为医疗费用提供津贴，否则该计划将支付医疗费用.
  2. 是的Discussion

Q&A #81-10 and Article III A. 雇主福利计划(2)(a)规定，如果紧急医疗是在出现急性医疗症状后48小时内进行的，则属于承保福利. Q&第81-85条规定，在先前已提供治疗的急性症状再次出现后48小时内提供急诊室护理.

急诊室的记录表明，病人在接受急诊室治疗之前已经患病四天. 然而, 该记录还证实，该雇员的头痛症状在他寻求急救的当天变得更严重了. 因此，他似乎在急性心脏病发作后48小时内接受了治疗

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medical symptoms. The Trustees note that the Employee attempted to contact his physician, but was unable to do so, prior to seeking care at the local emergency room.

A皇冠搏彩中心网站的医疗顾问审查了本案提供的临床资料，认为症状和临床发现, as recorded, justify the Employee’s seeking emergency medical care. In addition, 顾问指出，主治医生认为雇员的头痛严重到需要开具麻醉止痛药的处方.

因为病人的情况确实需要进行紧急医疗评估，而且治疗是在出现急性症状后48小时内进行的, the 雇主 is responsible for payment of the emergency room charges.

Opinion of the Trustees
The 雇主 is responsible for payment of the emergency room charges.