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OPINION OF TRUSTEES _____________________________________________________________________________
Complainant: Respondent: 连杆箱编号:
受托人:
在再保险
员工
雇主
88-853 - 1995年8月3日
托马斯·F. 迈克尔·康纳斯. 霍兰德，马蒂·D. 哈德逊和T. 华莱士.
罗伯特。
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of health benefits coverage for emergency room services under the terms of the 雇主 Benefit Plan.
背景事实
8月29日, 1993, the 员工 went to the emergency room of an area hospital because he began to have dizziness the day before, with pain radiating to his back. The 员工 stated he had had indigestion for two weeks. The emergency room record notes a history of hypertension (high blood pressure) for which he was on maintenance medication. The examining physician ordered an electrocardiogram (EKG) which was normal except for tachycardia (rapid heart beat).
The 雇主 provided benefits for the physician’s charges but denied benefits for the emergency room charges of $134.00, a pharmacy charge of $7.00, medical surgical supplies for $55 and a telemetry charge of $204.
争端
Is the 雇主 required to provide benefits for the emergency room and related charges incurred by the 员工 in his visit on August 29, 1993?
双方立场
受托人的意见
连杆箱编号. 88-853
第二页
Position of the 员工: The 雇主 is required to provide benefits for the emergency room and related charges because the symptoms had became worse within 48 hours of the 员工’s visit to the emergency room.
Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room and related charges because the treatment could have been rendered at a lower level of care.
相关的规定
第三条. A. (2) (a) states: 第三条 Benefits
A. 健康的好处
(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) provides benefits for emergency medical outpatient hospital services when the treatment is rendered within 48 hours of the onset of acute medical symptoms.
A Funds’ medical consultant has reviewed the medical records in this case and notes that the 员工’s dizziness began the day before treatment and that pain was radiating to the patient’s back. He also noted that the 员工’s symptoms and medical history concerned the attending physician enough for him to order an EKG. 出于这些原因, the medical consultant is of the opinion that the emergency room visit in this case would be considered medically appropriate.
因此, the Trustees conclude that the 员工’s use of the emergency room on August 29, 1993 was medically appropriate, and the 雇主 is required to provide benefits for the emergency room and related charges incurred.
受托人的意见 连杆箱编号. 第3页
受托人的意见
Consistent with the provisions of the 雇主 Benefit Plan, the 雇主 is required to provide benefits for the emergency room and related charges incurred by the 员工 on August 29, 1993.