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OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD Case No.

在再保险

员工
雇主
84-713 - 1990年8月22日

董事会:Joseph P. 康纳斯,老., Chairman; Paul R. Dean, Trustee; William Miller, Trustee; Donald E. 皮尔斯,小., Trustee; Thomas H. Saggau,受托人.

Pursuant to Article IX of the United Miner Workers of America (“UMWA”) 1960 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 health benefits for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

2月9日, 1987, the 员工’s spouse sought treatment at a hospital emergency room complaining of headache and pain in the left gum radiating to the left ear as a result of dental work (a root canal) that had been done earlier that day. The emergency room physician gave her an oral analgesic for pain and advised her to see her dentist in the morning. The 雇主 denied the charge related to the use of the emergency room.

争端

Is the 雇主 required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on February 9, 1987?

双方立场

Position of the 员工: The 雇主 is required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on February 9, 1987 because services were rendered in compliance with the terms of the 雇主 Benefit Plan.

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

Position of the 雇主: The 雇主 is not required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on February 9, 1987 because the 员工’s spouse was treated for pain as a result of a dental procedure, and dental services are specifically excluded from coverage under the 雇主 Benefit Plan.

Pertinent Provisions Article III 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

The 雇主 denied the emergency room charge on the basis that dental services are not covered under the 雇主 Benefit Plan. The 员工’s spouse actually had dental work prior to the visit. She went to the emergency room because of pain that resulted from the dental work. The dispute here is not whether the dental work is covered under the Plan; rather, the issue to be decided is whether the emergency room visit is covered under the Plan.

根据第三条. A. (2)(a) of the 雇主 Benefit Plan, benefits are provided for emergency medical treatment when it is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.

The hospital records from the emergency room visit on February 9, 1987 indicate that the 员工’s spouse had complaints of pain resulting from the dental work that had been done earlier that day. A Funds’ medical consultant has reviewed the records of the emergency room visit and has advised that there is no evidence that the patient’s symptoms were severe enough to warrant an emergency room visit. Because the emergency room care provided in this case was not prompted by acute medical symptoms that warranted emergency medical treatment, the Trustees conclude that the 雇主 is not required to pay the emergency room charge.

受托人的意见

The 雇主 is not required to pay the emergency room charge resulting from the 员工’s spouse’s evaluation and treatment on February 9, 1987.