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受托人的意见
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在再保险
投诉: 员工
被申请人: 雇主
ROD案例编号: 88-609 - 1992年12月16日
董事会:Joseph P. 康纳斯,老., Chairman; Paul R. 院长,受托人;
艾略特一. 西格尔,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, 受托人审查了有关根据雇主福利计划条款提供急诊室护理福利的争议的事实和情况.
背景事实
2月12日, 1992年，雇员的配偶在一家医疗中心的急诊科寻求医疗评估和治疗. 急诊科记录显示，患者连续三天无咳，并于前一天开始使用抗生素塞克洛. The emergency room physician had a chest x-ray taken, and treated and released the patient.
用人单位 provided benefits for the physician charge, but denied benefits for the chest x-ray, drug charges and the emergency room charge for this visit.
In addition to claiming benefits for the visit, the 员工 filed a “hold harmless” form covering the charges. 用人单位, 在回应中, 在此情况下，使用雇主福利计划的“保持无害”条款是不合适的.
争端
Is the 雇主 required to provide benefits for the chest x-ray, 2月12日雇员配偶的评估和治疗产生的药费和急诊室费用, 1992? If not, is the 雇主 required to hold the 员工 harmless for these charges?
双方立场
Position of the 员工: 用人单位 is required to provide benefits for the chest x-ray, drug charges and the emergency room charge incurred on February 12, 1992 because the 员工’s spouse had to visit the emergency room on that date. If the services were not medically necessary, the 雇主 should initiate “hold harmless” procedures.
Position of the 雇主: 用人单位 is not required to provide benefits for the chest x-ray, 2月12日雇员配偶的评估和治疗产生的药费和急诊室费用, 1992 because the visit did not take place within 48 hours of the onset of symptoms at the time of the visit. Also, the use of “hold harmless” procedures is not appropriate in this instance.
相关的规定
The Introduction to 第三条 of the 雇主 Benefit Plan 状态:
承保的服务应限于诊断或治疗疾病或伤害的合理和必要的服务，并以适当的护理水平提供, or are otherwise provided for in the Plan. 医生规定的程序或护理水平并不意味着它在医学上是合理的或必要的，也不意味着它在本计划范围内. In determining questions of reasonableness and necessity, 将适当考虑提供服务的社区医生的习惯做法. Services which are not reasonable and necessary shall include, but are not limited to the following: procedures which are of unproven value or of questionable current usefulness; procedures which tend to be redundant when performed in combination with other procedures; diagnostic procedures which are unlikely to provide a physician with additional information when they are used repeatedly; procedures which are not ordered by a physician or which are not documented in timely fashion in the patient’s medical records; procedures which can be performed with equal efficiency at a lower level of care. Covered services that are medically necessary will continue to be provided, 因此，本款不得被解释为减损本条款III所述的计划覆盖范围或资格.
第三条. A. (2)(a) of the 雇主 Benefit Plan 状态:
(2) 门诊医院福利
(a) Emergency Medical and Accident Cases
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.
第三条. A. (10)(g) 3. 状态:
3. 雇主和妇女协会一致认为，收费过高和保健费用不断上涨是一个共同问题，需要双方共同努力加以解决. 在任何情况下，提供者试图收取过高的费用或对医疗上不必要的服务收取费用, 如计划所界定, 来自受益人, the Plan Administrator or his agent shall, with the written consent of the Beneficiary, 试着解决这个问题, either by negotiating a resolution or defending any legal action commenced by the provider. 计划管理人或其代理人是否代表受益人协商事项的解决方案或为法律诉讼进行辩护, the Beneficiary shall not be responsible for any legal fees, 定居点, judgments or other expenses in connection with the case, but may be liable for any services of the provider which are not provided under the Plan. The Plan Administrator or his agent shall have sole control over the conduct of the defense, 包括对索赔是否应和解或对不利裁决是否应上诉的决定.
讨论
第三条. A. 《皇冠搏彩中心》第(2)款(a)项规定，在出现急性医疗症状后48小时内提供紧急医疗是一项承保福利.
紧急医疗记录显示，病人连续三天无咳，并于前一天开始使用抗生素塞克洛. A Funds’ medical consultant has reviewed the information present in this case and has advised that the patient was not seen within 48 hours of the onset of her complaint and was not suffering from any new or acute symptoms; there was no evidence of a new medical illness being present. Because the 员工’s spouse did not have acute medical symptoms that warranted emergency medical treatment, or continuing symptoms that became acute within 48 hours of the emergency room visit, 受托人的结论是，雇主不需要为雇员妻子2月12日的评估和治疗所产生的急诊室费用提供津贴, 1992. 用人单位, 然而, 是否需要为评估和治疗过程中的胸部x光检查和药费提供福利.
第三条. A. (10)(g) 3. 《皇冠搏彩中心网站》规定，计划管理人应尝试与寻求收取非医疗必要服务费用的提供者进行谈判或为受益人辩护. Whether the 雇主 negotiates a resolution or defends a legal action, the Beneficiary is not responsible for any expenses in connection with such charges. This is known as the Plan’s “hold harmless” provision.
持有无害的, 然后, 针对皇冠搏彩中心网站提出的过度收费或医疗上不必要的治疗索赔，为受益人提供辩护. In the case of an initial visit to an emergency room, the decision to seek treatment there is usually made by the Beneficiary. 实际上, the emergency room will essentially accept and screen all patients who present themselves for medical care. 急诊室的工作人员必须经常进行诊断性检查，以排除以及定义和治疗疾病或损伤. Charges would be incurred for such medically necessary services, even in those instances where it is determined that the patient did not require emergent care. 然而, 受益人前往急诊室的决定本身可能构成对该设施的不必要使用.
如前所述, the Funds’ medical consultant has found that the patient had had a non-productive cough for three days, and had been started on an antibiotic the day before. Rather than returning to or telephoning the physician who prescribed the antibiotic, the patient visited an emergency room the following evening. The consultant found no evidence in the emergency room record of a worsening condition within 48 hours, 或者新的急性医学症状. 在这种情况下，援引保持为无害将相当于为受益人的行为辩护, since the decision to use the emergency room was the patient’s own, 现有的证据表明，急诊室的使用不适合病人当时的情况.
受托人的意见
雇主不需要为雇员配偶2月12日的评估和治疗所产生的急诊室费用提供补贴, 1992, nor to implement hold harmless procedures. 用人单位 is required to provide benefits for the chest x-ray and drug charges incurred in the same visit.