受托人的意见
争议的解决
情况下没有. 88-064
第1页 ______________________________________________________________________________

OPINION OF TRUSTEES ______________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

员工

雇主
88-064 - 1989年1月13日

在再保险

董事会: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

11月12日, 1987, the 员工 sought medical evaluation and treatment at a hospital emergency room. According to the hospital’s emergency room record, the 员工 was experiencing cramping abdominal discomfort, 广义的疼痛, diarrhea and a low-grade fever which began on November 11, 1987. The 员工 was diagnosed as having probable gastroenteritis. The 雇主 denied charges related to the use of the emergency room, stating that it found no evidence that the 员工’s symptoms had become acute or had changed within 48 hours of the emergency room visit and that no emergency medical treatment was rendered.

争端

Is the 雇主 responsible for payment of the emergency room charges resulting from the 员工’s evaluation and treatment on November 12, 1987?

双方立场

Position of the 员工: The 雇主 is responsible for payment of the emergency room charges resulting from the 员工’s evaluation and treatment on November 12, 1987, because such treatment was medically necessary.

受托人的意见 争议的解决 情况下没有. 88-064
第二页

Position of the 雇主: The 雇主 is not responsible for payment of the emergency room charges because emergency medical treatment was not rendered within 48 hours following the onset of acute medical symptoms.

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 Pian provides that emergency medical treatment is a covered benefit when it is rendered within 48 hours following the onset of acute medical symptoms.

The emergency room record indicates that the onset of the 员工’s medical symptoms occurred on the day prior to the emergency room visit. A Funds’ medical consultant has reviewed the records of the emergency room visit in question and has stated that the record indicates that the 员工 had significant symptoms of acute abdominal pain and a fever. 顾问说, 鉴于这些症状, the 员工 would not have known whether he was suffering from acute abdominal pain which might require emergency surgery or from ordinary gastroenteritis. The consultant is of the opinion that the emergency room visit in this case was prompted by the onset of symptoms that were reasonably judged to be acute and that emergency medical evaluation and treatment were warranted in this case. Inasmuch as the 员工 received emergency medical evaluation and treatment within 48 hours following the onset of acute medical symptoms, the 雇主 is responsible for payment of the emergency room charges resulting from the 员工’s evaluation and treatment on November 12, 1987.

受托人的意见

The 雇主 is responsible for payment of the emergency room charges resulting from the 员工’s evaluation and treatment on November 12, 1987.