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OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD Case No:

在再保险

员工
雇主
84-330——1987年2月4日

Board of Trustees: Joseph P. 康纳斯,老., Chairman; Paul R. Dean,受托人; William B. Jordan,受托人; William Miller,受托人; Donald E. 皮尔斯,小.,受托人.

Pursuant to Article IX of the United Mine Workers of America (“UMWA”) 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

1月24日, 1986, the 员工 sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, the 员工’s condition was “non-urgent” and his complaints were “cold, 喉咙痛, 耳朵堵塞, and upset stomach the day before.” The onset of these symptoms was recorded as January 18, 1986.

The 雇主’s insurance carrier paid the physician’s charge for evaluation and treatment, but denied charges related to the use of the emergency room on the grounds that emergency medical treatment was not sought within 48 hours of onset of medical symptoms.

争端

Is the 雇主 responsible for payment of the emergency room charges resulting from the 员工’s evaluation and treatment on January 24, 1986?

各方立场

Position of the 员工: The 员工 maintains that benefits for medical services received at the outpatient department of the hospital are owed him under the terms of the Coal Wage Agreement of 1984.

Opinion of Trustees Resolution of 争端 Case No. 第2页

Position of the Respondent: The 雇主 maintains that benefits for emergency room services are not covered because they were not sought as a result of acute medical symptoms.

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

Benefits are provided for a beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, providing such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.

讨论

根据第三条. A. (2) (a) of the 雇主 Benefit Plan, covered medical emergency medical treatment must be rendered as a result of either an accident or acute medical symptoms. The emergency room record indicates that the patient’s flu-like symptoms first started six days prior to the date he obtained the emergency room services. The record also indicates that the 员工’s condition was “non-urgent” (as opposed to “emergency” or “urgent”). There is no evidence to indicate that the 员工’s symptoms had become acute within the 48 hours preceding the emergency room visit.

A Funds’ medical consultant has reviewed the clinical information presented in this case and is of the opinion that the symptoms and clinical findings did not justify emergency medical treatment. Since the 员工’s symptoms were not acute and had not changed within the preceding 48 hours in such a manner that would indicate a potentially acute situation, the emergency room treatment is not a covered benefit.

受托人的意见

The 雇主 is not responsible for the payment of the emergency room charges resulting from the 员工’s evaluation and treatment on January 24, 1986.