受托人的意见
争议的解决
情况下没有. 88-294
第1页 _____________________________________________________________________________

OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: ROD 情况下没有:

在再保险

员工
雇主
88-294 - 1990年11月14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 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 for an 员工’s daughter under the terms of the 雇主 Benefit Plan.

背景事实

12月25日, 1989, the 员工’s spouse took her 7-year-old daughter, 谁有哮喘?, to the emergency room for evaluation and treatment because she was having difficulty breathing. According to the information submitted, the 员工’s daughter had been experiencing cold symptoms for a few days prior to the emergency room visit. The 员工’s spouse states that she sought emergency medical attention for her daughter because the symptoms had worsened and, 因为今天是圣诞节, no other physician was available. The diagnosis provided by the emergency room physician who evaluated the 员工’s daughter was early bronchopneumonia and asthma. He prescribed treatment with an oral bronchodilator (SloBid), 抗生素(丁苯唑), and a cough suppressant (Tussconex).

The 雇主 provided benefits for the physician, 化验及药剂收费, but denied benefits for the emergency room charge.

争端

Is the 雇主 responsible for payment of the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on December 25, 1989?

双方立场

Position of the 员工: The 雇主 is responsible for payment of the emergency room charge because the 员工’s daughter, 谁有哮喘?, was having difficulty breathing and the emergency room was the only facility available at that time for treatment.

受托人的意见 争议的解决 情况下没有. 88-294
第二页

Position of the 雇主: The 雇主 is not responsible for payment of the emergency room charge because treatments was not rendered within 48 hours of 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 Plan 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 员工’s daughter had cold symptoms for a few days prior to the emergency room visit. The record also indicates that the cough had worsened on the day of the visit. The 员工’s spouse has stated that because it was Christmas Day, no 医生tor was available to see her daughter except at the emergency room.

A Funds’ medical consultant has reviewed the information presented in this case and is of the opinion that, given the patient’s history of pneumonia and asthma and the emergency room physician’s diagnosis of early bronchopneumonia and asthma, the patient’s worsening respiratory symptoms were acute medical symptoms that warranted emergency medical treatment. 因此, the Trustees find that the 雇主 is required to pay the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on December 25, 1989.

受托人的意见

The 雇主 is responsible for payment of the emergency room charge resulting from the 员工’s daughter’s evaluation and treatment on December 25, 1989.