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OPINION OF TRUSTEES _____________________________________________________________________________

Complainant: Respondent: ROD Case No:

受托人:

员工
雇主
93-012 - 1996年7月1日

在再保险

托马斯·F. 迈克尔·康纳斯. 霍兰德，唐纳德·E. 皮尔斯,小. 和艾略特A. 西格尔.

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

The 员工 sustained a cut on his arm. 4月29日, 1994, 星期五晚上, after noticing a red line going up his arm that he thought might be blood poisoning, the 员工 sought treatment at a hospital emergency room. Although the 员工 was in no acute distress at the time, the physician diagnosed his condition as cellulitis (infection) and ascending lymphangitis that required immediate antibiotic intervention. The medical file noted that the 员工 is allergic to penicillin.

The 雇主 has denied benefits, saying that the case was not considered an emergency. 争端

Is the 雇主 required to provide benefits for the 员工’s emergency room visit on April 29, 1994?

Positions of the Parties

Position of the 员工: The 雇主 is required to provide benefits for the emergency room visit because the treatment was due to an injury and was given within 24 hours of the onset of acute symptoms.

Position of the 雇主: The 雇主 is not required to provide benefits because there was no emergency.

相关的规定

Opinion of Trustees ROD Case No. 第2页

第三条A. (2) (a)规定:
(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 benefits for outpatient hospital care when treatment is required for an injury or as the result of an accident provided the care is rendered within 48 hours following the onset of acute symptoms or the occurrence of the accident. The 员工 went to the hospital emergency room immediately upon noticing the red line on his arm. The emergency room physician diagnosed the case as cellulitis, a form of infection that requires immediate treatment to prevent spreading or further complications. A Funds’ medical consultant has reviewed the documentation in this case and has concluded that the 员工’s condition required immediate evaluation and treatment and that care should not have been delayed for two or three days. 因此, the 雇主 is required to provide benefits for the 员工’s emergency room visit on April 29, 1994.

Opinion of the Trustees

Consistent with the provisions of the 雇主 Benefit Plan, the 雇主 is required to provide benefits for the 员工’s emergency medical treatment on April 29, 1994.