______________________________________________________________________________

受托人的意见
______________________________________________________________________________

在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 88-743 - 1995年5月4日

受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，马蒂·D. 哈德森和罗伯特·T. 华莱士.

The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room care under the terms of the 雇主 Benefit Plan.

背景事实

5月19日, 1992, the 员工 sought treatment at a local hospital emergency room complaining of “sinus problems”, 发热, 咳嗽和充血, 在拜访前4到5天开始. The emergency room physician’s dictated report indicates that the 员工 also reported experiencing facial pressure and nasal drainage for five days.

The emergency room physician diagnosed the condition as sinusitis. The 员工 was prescribed Entex-LA for 交通拥堵, Ceclor 500 mg. (一种抗生素)和万西纳斯鼻吸入器. He was instructed to return to the emergency room in 48 hours if he was no better.

The 雇主 provided benefits for the emergency room physician’s charges, but denied the emergency room facility charge and the pharmacy charge as not having been incurred within 48 hours of the onset of acute medical symptoms.

争端

Is the 雇主 required to provide benefits for the emergency room charge and the pharmacy charge resulting from the 员工’s evaluation and treatment on May 19, 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: The 雇主 is required to provide benefits for the emergency room and pharmacy charges incurred on May 19, 1992, because the 员工 awakened that day with acute medical symptoms necessitating emergency care and treatment.

Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room and pharmacy charges incurred by the 员工 on May 19, 1992, because the 员工’s condition was not a medical emergency requiring emergency medical care, and because the 员工 himself stated that his symptoms had begun four to five days prior to the emergency room visit. Also, the use of “hold harmless” procedures is not appropriate in this instance.

相关的规定

第三条. A. 雇主福利计划第(2)(a)条规定:

(2) 门诊医院福利

(a) 紧急医疗和意外案件

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.

第三条. A. (10)(g) 3. 有关部分各国:

3. The 雇主 and the UMWA agree that excessive charges and escalating health costs are a joint problem requiring a mutual effort for solution. In any case in which a provider attempts to collect excessive charges or charges for services not medically necessary, 如计划所界定, 来自受益人, 计划管理人或其代理人应, 经受益人书面同意, 试着解决这个问题, either by negotiating a resolution or defending any legal action commenced by the provider.

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 record indicates that the patient complained of sinus problems with 发热, 交通拥堵, and cough beginning 4 or 5 days prior to the emergency room visit. A Funds’ medical consultant has reviewed the information presented in this case, including the dictated notes of the emergency room physician, and has advised that the patient’s symptoms had been present for 4-5 days with no documentation of new symptoms or acute worsening of the symptoms associated with sinusitis. 另外, the consultant noted that there was no documentation of a 发热, 呕吐, 腹泻, 或如雇员所述的头晕. Because the 员工 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, the Trustees conclude that the 雇主 is not required to provide benefits for the emergency room charge resulting from the 员工’s evaluation and treatment on May 19, 1992, but is required to provide benefits for the pharmacy charge. The 雇主 has provided benefits for the emergency room physician’s charge associated with the visit.

第三条. A. (10)(g) 3., 保持无害条款, provides that the Plan Administrator shall attempt to negotiate with or defend a Beneficiary against providers who seek to collect charges for services not medically necessary.

In ROD 88-609 (copy enclosed herein) the Trustees decided that when an 员工 made an inappropriate decision, 独立于专业医疗建议, 去急诊室寻求治疗, invoking hold harmless would amount to defending the 员工 against his own actions since the emergency room cannot turn away an individual seeking care. Therefore, under facts such as these, application of hold harmless is inappropriate.

受托人的意见

The 雇主 is not required to provide benefits for the emergency room charge resulting from the 员工’s evaluation and treatment on May 19, 1992, 也没有实施无害程序, but is required to provide benefits for the pharmacy charge incurred on that date.