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受托人的意见
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在再保险

原告: 员工
被申请人: 雇主
ROD案例编号: 93-071 – November 8, 1996

受托人: 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

On August 17, 1994, the 员工 began feeling ill while at work. At the end of his shift, he went to his physician but found the office closed. He then went to a hospital emergency room where he was examined and given diagnostic tests.

The 雇主 provided benefits for the emergency room physician’s charge but has denied benefits for the emergency room facility charge of $77 as well as $60 for diagnostic laboratory tests.

争端

Is the 雇主 required to provide benefits for the emergency room facility charge and diagnostic laboratory tests?

Positions of the Parties

Position of the 员工: The 雇主 is required to provide benefits for the emergency room charge and diagnostic laboratory tests because the 员工’s physician’s office was closed.

Position of the 雇主: The 雇主 is not required to provide benefits for the emergency room charges because there was no medical emergency and the services could have been provided at a lower level of care.

相关的规定

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) provides benefits for emergency medical treatment that is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident.

A Funds’ medical consultant has reviewed the medical documentation submitted in this case, and notes that these records reveal normal vital signs and the only abnormal physical finding being a slightly red throat. The consultant has determined that the patient did not exhibit acute symptoms and that the treatment rendered could have been provided at a lower level of care. 因此, consistent with the provisions of the 雇主 Benefit Plan, the 雇主 is not required to provide benefits for the use of the emergency room. 然而, the 雇主 is required to provide benefits for the diagnostic laboratory tests since benefits would have been provided for these at a lower level of care.

Opinion of the Trustees

The 雇主 is not required to provide benefits for the emergency room facility charge, but is required to provide benefits for the diagnostic laboratory tests in connection with the 员工’s emergency room visit on August 17, 1994.